A Huge Victory for Medicare Beneficiaries: Removal of the “Improvement Standard”

By: Jerold E. Rothkoff

Some of you may have heard me say this before – That “failure to improve” should not be the deciding factor in terminating an individual’s Medicare skilled nursing benefit.  Finally, Federal officials agree with this statement.  Late last week, the Center for Medicare Advocacy and the Centers for Medicare and Medicaid Services (CMS) have agreed to settle the “Improvement Standard” case of Jimmo v. Sebelius.

Under the settlement agreement, which I have attached the link below, the Medicare policy manual will be revised to correct any suggestion that continued Medicare skilled nursing coverage is dependent on the beneficiary improving.  Medicare will be required to pay for services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is expected to improve.

CMS will also be obligated to undertake an educational campaign to get the word out to providers, contractors, and adjudicators that they should not base coverage on the potential for improvement, but on the need for skilled care.

The net result is that Medicare beneficiaries with chronic conditions will find it easier to qualify for coverage for home care, skilled nursing home, and outpatient therapy.  This will give millions of Americans who suffer from chronic and debilitating conditions a fair chance to obtain the Medicare coverage for which they qualify and the health care treatments they need to remain as healthy and productive as possible. Ending application of the Improvement Standard is a life or death issue for countless Americans

Congratulations to Judith Stein, the Executive Director of the Center for Medicare Advocacy, and her staff for their fantastic advocacy.  We all owe them a debt of gratitude.

Below is the NY Times article link as well as the proposed class action settlement.  The proposed settlement can be used as an immediate advocacy tool to argue maintenance services are equally covered as improvement services if one requires skilled personnel.

Should you have any questions, please feel free to contact our office.

“Settlement Eases Rules for Some Medicare Patients”


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