Q.  Following my husband’s return home from a hospital stay, Medicare paid for a home health agency to give him therapy at home.  However, we were just told that Medicare would stop paying for these visits because his condition was not improving.  Does that sound right?

A.  No, it does not.  Some background may be helpful: for many years, home health agencies and nursing homes who contract with Medicare routinely terminated Medicare coverage for a beneficiary who had stopped improving, even though nothing in the Medicare law required improvement as a condition for continued coverage.  In practice, both Medicare and the contract providers wrongfully applied an “improvement standard” to deny continued coverage to patients who had “failed to improve” or who had “plateaued”.  In short, once beneficiaries failed to show progress continued coverage was denied.  However, this misapplication of Medicare law was successfully challenged in a class-action lawsuit entitled Jimmo v. Sebelius, which was settled last year with nationwide impact. 

Under the settlement agreement, Medicare agreed to abandon its use of the so-called “improvement standard”.  It also agreed to revise its Medicare Benefit Policy Manual and to issue written instructions to its healthcare providers to make clear that continued  coverage of skilled nursing and therapy services does not turn on the presence of a beneficiary’s potential for improvement, but rather on whether he or she needs skilled care to “maintain” his or her current condition or to “slow further deterioration”.  Under the new policy, if your husband would be at risk for losing function or “backsliding”, then continued therapy ought to be provided and covered by Medicare.

Unfortunately, even though the Jimmo settlement is more than a year old,  we find that many healthcare providers are unaware of the end of the old “improvement standard”.  As a result, many seniors still experience premature Medicare coverage terminations because they are not improving.  This is especially problematic for person suffering with chronic conditions such as multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, ALS, heart disease and stroke.  The good news, however, is that advocacy on your part can play a big role in correcting premature coverage terminations.

If you receive a notice that Medicare coverage is about to terminate, consider an immediate appeal.  Talk to your husband’s doctor and ask for a written chart note that continued therapy is necessary for your husband to “maintain” function and/or to “slow further deterioration”.  To further aid you in your appeal, download the excellent Self-help Packets available for free on the website of the Center for Medicare Advocacy at www.MedicareAdvocacy.org, or by calling 860-456-7790.  Individualized Self-Help Packets are available for denials of outpatient therapy, home healthcare, nursing home, and the misuse of hospital “observation status”.

So, based upon the Jimmo class action and the end of the so-called “improvement standard”, your husband may be entitled to continued covered therapy.  Remember that advocacy does work. Also, by educating your husband’s providers as to the new rule under the Jimmo settlement, you may also indirectly help other patients who might have been similarly misinformed and could themselves benefit from continued covered therapies.