THE MEDICARE MYTH: THE “IMPROVEMENT STANDARD”

Anyone that has Medicare or has helped a Medicare recipient deal with their medical issues has probably been told that Medicare will only cover services if the patient is improving. Once they “plateau,” Medicare will stop covering the services. Even though people are told this everyday by medical providers, this is not true. There was a class action suit brought against the Centers for Medicare and Medicaid Services (CMS) by the named Plaintiff Glenda Jimmo who was blind and had lost a leg as a result of diabetes. She was being denied Medicare coverage for her homecare under the guise that she would not improve and will continue to need a wheel chair. In 2013, The Federal Court accepted a settlement between the class of people that Ms. Jimmo represented and CMS. As a result, Medicare Policy now clearly states coverage,

 “... does not turn on the presence or absence of a beneficiary's potential for improvement, but rather on the beneficiary's need for skilled care. Skilled care may be necessary to improve a patient's condition, to maintain a patient's current condition, or to prevent or slow further deterioration of the patient's condition." (CMS Transmittal 179, Pub 100-02, 1/14/2014).  

 In addition, The Medicare Benefit Policy Manual Chapter 15, §220.2 specifically provides: “Outpatient therapy services can be covered by Medicare to improve, and to maintain, prevent, or slow decline of an individual’s condition, when the skills of a therapist are necessary for the services to be safe and effective.” 

Although this particular excerpt addresses outpatient care, the same holds true for inpatient care as well. The Center for Medicare Advocacy has a tremendous amount of information to help you effectively advocate for yourself or your loved one. [Read More Here]