shouldn’t have to decline in order to get the care they need.
executive director of the Center for Medicare Advocacy
Oct. 27, 2014 - A 78-year-old
Vermont mother of four who helped change Medicare coverage for millions
of other seniors is still fighting to persuade the government to pay for
her own care. Glenda Jimmo, who is legally blind and has a
partially amputated leg due to complications from diabetes, was the lead
plaintiff in a 2011 class-action lawsuit seeking to broaden Medicare’s
criteria for covering physical therapy and other care delivered by
In 2012, the government agreed to
settle the case, saying that people cannot be denied coverage solely
because they have reached a plateau and are not getting better.
The landmark settlement was a
victory for Medicare beneficiaries with chronic conditions and
disabilities who had been frequently denied coverage under what is known
as “the improvement standard” —a judgment about whether they are likely
to improve if they get additional treatment. It also gave seniors a
second chance to appeal for coverage if their claims had been denied
because they were not improving.
Jimmo was one of the first seniors
to appeal her original claim for home health care under the settlement
that bears her name. But in April, the Medicare Appeals Council, the
highest appeals level, upheld the denial. The judges said they agreed
with the original ruling that her condition was not improving — criteria
the settlement was supposed to eliminate.
After running out of options
appealing to Medicare, her lawyers filed a second federal lawsuit in
June to compel the government to keep its promise not to use the
improvement standard as a criterion for coverage. They are asking
Medicare to pay for the home health care that Jimmo received for about a
year beginning in January 2007.
“There was really no expectation
that she would improve — she was getting skilled nursing and home health
care to maintain her condition and reduce complications,” said Michael
Benvenuto, director of Vermont Legal Aid’s Medicare Advocacy Project,
who has filed review requests for 13 other seniors. “It shows there may
be real problems with implementing the settlement at the very highest
In the settlement,
Medicare officials had agreed
to rewrite Medicare’s policy manuals to clarify that as long as patients
otherwise qualify for coverage - for instance, they have a doctor’s
order for skilled care to preserve their health or to prevent or slow
deterioration - Medicare must pay for therapy and other care at home, in
a nursing home or office. Each of those settings has additional
restrictions: for instance, nursing home coverage still requires a prior
three-day hospital admission, and there are dollar limits (with
exceptions) on physical, occupational and speech therapy.
They also agreed to educate
providers, billing contractors and appeals judges about the change.
Nearly five million Medicare
beneficiaries received physical, occupational or speech therapy in 2011,
with an average of 16 visits, according to the Medicare Payment Advisory
Commission, an independent group that advises Congress.
“People shouldn’t have to decline
in order to get the care they need,” Stein said. “It is ironic and also
not unusual for people to find themselves in that circumstance. We are
unfortunately finding providers are still reluctant to provide care
because they are so accustomed to Medicare denials based on a need for
The Parkinson’s Action Network, one
of the seven advocacy groups that had joined the original Jimmo lawsuit,
still receives several calls a week from patients who are told Medicare
won’t cover their care because they are not improving. But Parkinson’s
disease is an incurable chronic degenerative neurological condition.
“Just maintaining function is a
victory,” said Chief Executive Ted Thompson.
Joshua Cohen, a physical therapist
with a small practice near Chapel Hill, N.C., is worried claims he
submits to Medicare may still be questioned or denied. When patients are
not progressing, he tells them they can continue therapy if they sign
Medicare’s “advanced beneficiary notice of non-coverage”
form, promising to pay
the bill if Medicare doesn’t. “That in and of itself often prevents
further therapy,” he said because patients are afraid they will end up
with the bill.
Gabe Quintanilla, a lawyer for the
city of San Antonio, refused to sign the non-coverage forms when he was
told at least seven times this year that his 92-year-old mother’s
physical and speech therapy would end because she was not improving
following her hospitalization for a stroke. One doctor predicted she
would continue to decline and suggested hospice care.
“The only reason I was able to keep
my mother’s therapy going is because I sent a copy of [the] Jimmo
[settlement] to her doctor, her insurance company and the home care
agency,” he said. His mother has a Medicare Advantage plan, a private
health insurance program that must also comply with the settlement. He
discovered it “by accident,” while researching legal options on the
His mother eventually left the
hospital and received follow-up care at a nursing home before returning
home. Despite the dire predictions, what began as maintenance therapy
has led to unexpected, if slight, improvements.
video he posted on YouTube, he
leans in close to share his prediction that the Spurs are going to beat
Portland. And she smiles, pleased that her favorite basketball team
won’t let her down.
“The Jimmo settlement saved my
mother’s life,” he said.
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