Friday, October 31, 2014

CMS Finally Pays Glenda Jimmo for Her Maintenance Therapy

Dan Ciolek

Per a Center for Medicare Advocacy (CMA) announcement , the Centers for Medicare and Medicaid Services (CMS) agreed to settle the recently filed Jimmo v. Burwell lawsuit on October 29, and will actually cover her home health maintenance therapy provided several years ago, which was previously denied and led to the landmark Jimmo v. Sebilius settlement.

In April 2014, despite the 2012 settlement agreement in which CMS agreed that Medicare cannot deny (Part A, Part B, or Medicare Advantage) payment for therapy or nursing services (provided in home health, SNF, or outpatient settings) merely on the basis that the condition/function was not improving, Ms. Jimmo’s claim was again denied at the 4th level of appeal due to “lack of improvement”, which prompted the new lawsuit settled on October 29.

This is great news in that it affirms that maintenance services are a necessary covered service for beneficiaries with chronic and/or progressive conditions that are at risk for decline in health and function without skilled interventions performed by qualified individuals, and that cannot be safely and effectively be performed by the patient or nonskilled caregivers.

There is one very valuable piece of information in the CMA press release that should not go unnoticed. Despite having a number of chronic health conditions, the press release notes that Ms. Jimmo developed a condition that required temporary SNF care, that she is currently getting SNF therapy services, and that she is expected to return home soon. There are several messages that can be inferred from this story:

1) people with chronic health problems can benefit from maintenance therapy as a covered Medicare benefit,

2) people with chronic health problems can decline without maintenance therapy requiring more costly inpatient services, including the woman who has become the poster child for maintenance therapy, and

3) people with chronic health problems, with recent decline can benefit from skilled nursing facility care, and can return to their home as a result of quality nursing and rehabilitation care.

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