Wednesday, March 2, 2016

AHCA/NCAL Submit Legal Declaration Attesting that CMS is Noncompliant with Jimmo v Sebelius Settlement Agreement

Dan Ciolek


On February 23, 2016, AHCA/NCAL submitted a Declaration in Support of Motion for Resolution of Noncompliance with the Jimmo v Sebelius Settlement Agreement. This declaration will be introduced as part of continued legal action from the Center for Medicare Advocacy, the organization that was a lead plaintiff in the initial class action complaint filed in early 2011.


As you recall, on January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in Jimmo v. Sebelius​ that Medicare contractors were inappropriately applying an “improvement standard” in making claims determinations for Medicare coverage involving skilled care (e.g., SNF, home health and outpatient therapy in an assisted living center). In the settlement agreement, the Centers for Medicare and Medicaid Services (CMS) agreed to finalize and issue revised materials and to undertake an educational campaign to assure that patients with chronic or degenerative conditions could receive coverage for skilled nursing and therapy services aimed at maintaining function, or slowing down predictable decline. Details may be found at the AHCA “Improvement Standard” webpage.


In the February 23 Declaration, Mike Cheek, Senior Vice President, Finance Policy, and Legal Affairs states that the organization does not believe that the CMS education effort has been “…adequate, timely, or complete.” Additionally, he states that “AHCA/NCAL is increasingly concerned about the lack of serious consideration of the needs of beneficiaries requiring skilled maintenance nursing and therapy services in quality and resource use measures being developed for public reporting and payment purposes by CMS and its contracted measure developers.”

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