Advocates Note Skilled Care Settlement is Retroactive

The recent landmark settlement of a case in federal court in favor of impaired patients seeking Medicare benefits is retroactive to January 18, 2011, according to the Connecticut-based Center for Medicare Advocacy (CMA), the consumer organization that led the class action suit.

The settlement of Jimmo v. Sebelius approved January 24, 2013 by a federal judge means that under the Medicare program, the Department of Health & Human Services can no longer deny skilled nursing care based on a finding that a patient’s condition isn’t expected to improve. The settlement underscores that services must be reimbursed so long as they’re medically necessary to maintain, rather than improve, a patient’s condition. The settlement applies to home health, outpatient therapy and skilled nursing facility benefits but doesn’t change the 100-day “spell of illness” benefit period coverage limitation.

CMA emphasizes that re-reviews are available for beneficiaries with denials of physical, occupational or speech therapy that were final after January 18, 2011. Providers and Medicaid agencies aren’t eligible for re-reviews. HHS will shortly undertake a major educational campaign explaining the Jimmo settlement to providers and beneficiaries across the nation. For additional information, visit www.medicareadvocacy.org.