Florida Elder Law & Estate Planning Blog

Medicare staff still using improvement standard to deny claims

physical therapy

Medicare beneficiaries must be covered for skilled rehabilitation services if the services help the beneficiary maintain his/her level of functioning and prevent disease progression. Medical improvement is not necessary for coverage. This was made clear in the Jimmo v. Sibelius case, as reported in a prior post. That ruling  is of particular importance to those with chronic conditions such as arthritis, cardiac disease, Parkinsons, etc.

Unfortunately, even now, seniors are often wrongly denied Medicare coverage based on the old improvement standard.  The problem has been fairly widespread, and led to a considerable outcry from Medicare advocates.

In response to a lawsuit brought by several Medicare advocacy organizations, a federal judge ruled on Feb. 2 that Medicare must better inform employees that otherwise eligible beneficiaries are covered for skilled rehabilitation so long as it prevents further deterioration. Among the required corrective actions included in the ruling: Medicare must maintain a web page devoted to the Jimmo v. Sibelius case, clearly explaining how claims should be handled. In addition, the agency must provide appeals judges, claims processors and other relevant staff with new training. You can read the judge’s ruling here.  Medicare has until September 4 to comply.

So what does this all mean for you if you are a Medicare beneficiary or caring for one? First, be sure to discuss care and coverage with your medical providers, bearing in mind that the only criterion is whether skilled rehabilitation services are necessary, not if they produce improvement. If you have been denied coverage on the basis of not meeting the improvement standard, your appeal will now have greater weight. (Information on Medicare appeals here.)