There is some evidence that the Medicare established eligibility standards for skilled care are not being followed. These were effective as of January, 2014. Beneficaries......FOR MORE CLICK TITLE... no longer had to improve but only had to maintain their level of care to be on or to stay on skilled care in a nursing home or in the community. Individuals may appeal.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf.  The CMS MLN Matters article is also available on the CMS site under “Downloads” at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8458.pdf

As CMS states in the Transmittal announcing the Jimmo Manual revisions: 

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning.

The proposed Jimmo settlement agreement[2] was originally filed in federal District Court on October 16, 2012. The plaintiffs joined with the named defendant, Secretary of Health and Human Services Kathleen Sebelius, in asking the federal judge to approve the settlement of the case. With only one written comment received, and no class members appearing at the fairness hearing to question the settlement, Chief Judge Christina Reiss granted the motion to approve the Settlement Agreement on the record, while retaining jurisdiction to enforce the agreement in the future, as requested by the parties.

With the settlement now officially approved, the Centers for Medicare & Medicaid Services (CMS) is tasked with revising its Medicare Benefit Policy Manual and numerous other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings.  CMS must also develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve. 

It is important to note that the Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now – while CMS works on policy revisions and its education campaign. The Center is hearing from beneficiaries who are still being denied Medicare coverage based on an Improvement Standard, but coverage should be available now for people who need skilled maintenance care and meet any other qualifying Medicare criteria. This is the law of the land – agreed to by the federal government and approved by the federal judge.  We encourage people to appeal should they be denied Medicare for skilled maintenance nursing or therapy because they are not improving.

Patients should discuss with their health care providers the Medicare maintenance standard and whether it is applicable to them.  Health care providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline.  Under the maintenance standard articulated in the settlement, the important issue is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve."

CMS has issued a Fact Sheet outlining the Jimmo v. Sebelius. settlement.  Use this fact sheet now as evidence that skilled maintenance services are coverable for skilled nursing facility care, outpatient therapy, and home health care.  The Center for Medicare Advocacy has Self-help Packets to help pursue Medicare coverage, including for skilled maintenance nursing and therapy.

For answers to many common questions about the Settlement, see our Frequently Asked Questions.

The Jimmo settlement also establishes a process of "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) that became final and non-appealable after January 18, 2011 because of the Improvement Standard.  You can access a request for re-review form here.  CMS discusses and links to the form here.

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The Centers for Medicare & Medicaid Services (CMS) published revisions to the Medicare Benefit Policy manual on December 6th to clarify that skilled care and skilled therapy can be covered for conditions that will not improve.  The revisions will become effective January 7, 2014 (marked in red in the following link http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R175BP.pdf).  These revisions are a direct result of the January 24, 2013 settlement of the Jimmo v. Sebelius case.

The revisions clarify Medicare’s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.  The need to show improvement has been challenged for decades, and the Medicare revisions are a huge victory for people with Alzheimer’s disease, multiple sclerosis, Parkinson’s disease and other chronic conditions. 

Here’s what you can do:

CMS is starting an Education Campaign to ensure that Medicare determinations are based on the need for skilled care – not on the ability of an individual to improve. 

The Center for Medicare Advocacy (CMA) below provides additional details.

Improvement Standard Update: CMS Revises Medicare Policy to Ensure Coverage for Skilled Maintenance Care

The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised pursuant to the Jimmo vs. Sebelius Settlement.  The Jimmo case ended a longstanding practice denying Medicare coverage to people who  had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday December 6, 2013. They pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) [nursing home category], Home Health care (HH), and Outpatient Therapies (OPT). 

As CMS states in the Transmittal announcing the Jimmo Manual revisions: 

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning. 

“As with components of all settlement agreements, the Jimmo revisions are not perfect,” says Judith Stein, Executive Director of the Center for Medicare Advocacy. “But they do make it absolutely clear that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline – not just for improvement.”

Plaintiffs in Jimmo vs. Sebelius are represented by the Center for Medicare Advocacy and Vermont Legal Aid.  Jimmo is a certified national class action lawsuit brought by individual Medicare beneficiaries and national organizations. It was formally settled by the Plaintiffs and Secretary Sebelius on January 24, 2013, when federal Judge Christina Reiss approved the settlement Agreement.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website.  The CMS MLN Matters article is also available on the CMS site under “Downloads.”

Retweet our Tweets about the Jimmo Medicare revisions and help spread the news.

For more details on the Improvement Standard and the Jimmo case, see: http://www.medicareadvocacy.org/medicare-info/improvement-standard/.

 

Each state will set up market places where consumers can purchase health insurance as required by federal law. Below is a Q & A by Kaiser Health ...FOR MORE CLICK TITLE...News about this new system.

Benefits On Health Marketplace Plans Will Be Similar But Costs Will Vary

By Michelle Andrews | Kaiser Health News, Tuesday, July 30.
As the state health insurance marketplaces, also called exchanges, get set to launch in October, many people have questions about the coverage that will be offered there. Here are a few that were posed to me recently.

Q. Are there unintended consequences of shopping through an exchange? For example, are the benefits of a plan with a lower monthly premium less comprehensive than the benefits of an expensive plan? And are there plans available only to people who qualify for subsidies, so that once income increases, the consumer must switch to a different plan?

A. All plans sold on the exchanges must cover 10 so-called essential health benefits, including prescription drugs, emergency and hospital care, and maternity and newborn care.

For the most part, the plans will differ not in which benefits they cover but in the proportion of costs that consumers will be responsible for paying.

There will be four basic types of plans: Platinum plans will pay 90 percent of the cost of covered medical services, on average, while consumers will be responsible for 10 percent; gold plans will pay 80 percent; silver plans will pay 70 percent; and bronze plans, 60 percent. Premiums will vary based on those percentages, so platinum plans generally will be pricier than bronze ones.

Individuals and families with incomes up to 400 percent of the federal poverty level ($45,960 for an individual and $94,200 for a family of four in 2013) may be eligible for federal tax credits to help pay premiums.

Consumers “can use the premium subsidy to purchase any plan,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

If your income increases during the year, you may no longer qualify for the same level of assistance, but you won't have to switch plans. However, you may have to repay any overpayments that were made to insurers if your projected income turns out to be higher than your actual income. On the other hand, if your income falls, you may be eligible for a larger tax credit. That's why it's important to report any income changes to the exchange promptly.

A second type of subsidy available on the exchanges will reduce the amount that people owe in co-payments, deductibles and other out-of-pocket costs. The cost-sharing subsidy is available to individuals and families with incomes up to 250 percent of the poverty level ($28,725 for an individual and $58,875 for a family of four in 2013). To qualify for this subsidy, you must buy a silver plan, Park says. If your income changes, however, you won't be responsible for any overpayments.

Q. Once the exchanges open, how much will an insurer be allowed to increase premiums annually? And are those increases based on claims?

A. Premium increases are driven by many factors, including medical costs and the health of the people covered by a particular plan.

The Affordable Care Act discourages insurers from imposing unreasonable premium increases in a couple of ways. Insurers in the small-group and individual markets that want to raise premiums by 10 percent or more must submit data, projections and other information to justify the increase to state or federal regulators, who review the requests and make the information available to the public. Asking insurers to justify why they want to increase rates should act as a deterrent to unreasonable increases, experts say.

But the law doesn't give regulators new authority to refuse rate increases, says Timothy Jost, a law professor at Washington and Lee University in Lexington, Va. It does, however, provide funding for states to beef up their rate-review processes.

The Department of Health and Human Services says that increased scrutiny of insurance rates has led to a decrease in rate increases, says Jost, “and that's probably true.”

In addition, the law requires insurers to spend at least 80 percent of the money they collect in premiums on medical claims and quality improvements rather than on administrative activities such as marketing. If they exceed that limit, they must rebate the excess to consumers. Insurers will return $500 million to 8.5 million consumers -- about $100 per eligible family -- by mid-August of this year for overcharges in 2012, according to the Obama administration. Rebates may come in various ways, including a check or a reduction in the following year's premium.

Q. My parents are legal immigrants over 65 but not yet eligible to buy into Medicare because they haven't lived in the United States for five years. Will they be able to buy health insurance on the federal exchange?

A. Yes, legal immigrants will be able to shop for coverage on the exchanges, where they may be eligible for premium tax credits if their income is no more than 400 percent of the federal poverty level ($62,040 for a couple in 2013). Immigrants living in the United States without legal permission, on the other hand, are not permitted to buy coverage on the exchanges even if they wish to pay the entire premium out of pocket.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

 

Social Security The Chained CPI would reduce the amount which reciepients receive each year.:For many older Americans, Social Security is their primary source of income.  Based on the sequester, funding for congregate meals and "Meals on Wheels" has been cut.  Should we now cut their Social Security benefits because they are now buying generic corn flakes rather than chicken to prepare for their meals???

 

Social Security benefits are paid from the trust fund created by the FICA taxes paid by workers.  The only impact that Social Security can have on the federal deficit is that the trust funds are invested in government bonds--and obviously if the bonds are redeemed, then the federal deficit would increase.  There is no immediate need to consider redeeming any of these bonds--and if the cap ($113,700 in 2013) on FICA taxes were to be increased or eliminated, there would be no need to consider this in the foreseeable future. The following shows how social security benefits would decrease over time:  

CMS(Center for Medicare and Medicaid Services) has agreed to change its eligibility rules for those who need skilled nursing home and also in-home and ...CLICK TITLE FOR MORE.... outpatient care. Individuals will no longer have to show that they are improving in order to receive skilled care(in a nursing home or in the commnity).

 

Read the following:

 

This agreement was based on a class action law suit which was brought against the Federal government.

Look for  more information later about specifics and implementation date.

 

Clearly, some  residents will be able to stay longer in their Medicare A bed. This does not impact the maximum number of days allowed on one stay. Others will be able to continue their community based rehab services.

It will cost the Federal government additional dollars tho there may be some savings if services prevent admission to a nursing home or keep someone out longer.

 

Following is information about a bill in Congress which would address the hosptial "observation day" issue. Some individuals may go to a hospital for several days.....FOR MORE CLICK TITLE...  or longer and not be admitted. They are on "observation status". If they are sent to a nursing home those "observation days " do not count as hosptial days and so Medicare will not pay for their nursing home admission. the individual and he family are left with a very large bill which they did not expect.