Good news! Judge tosses “Medicare Improvement Standard”


R emember last November? Don’t feel bad, because I don’t, either; I think there were a few traumas sprinkled in there somewhere, like Part D “open enrollment” and an election and a holiday, and probably a few others that don’t need to be publicly shared, but for the sake of this morning’s missive, harken back to that part of last year and think, “Jimmo Settlement.”

What?

Good question, so let me take us down a rabbit trail on the way to an answer. And in order to get there from here, we need to understand a little something about Medicare, remembering that a “little something” is all any of us will ever understand about Medicare.

Here’s the deal: As way too many of us well know, for years and years Medicare has had an “improvement standard” that limited our access to Medicare-paid skilled nursing and therapy services (think, among other things, “Home Health”); in other words, when you stopped “improving,” services stopped.

Hmm … So, if I had a condition that was stable, chronic, not improving or that required such services to just keep things from getting worse (“maintenance only”), I was out of luck. Here are two surprises:

1. A lot of us have conditions like that;

2. Said “improvement standard” isn’t in Medicare law!

It was just some rule or regulation or standard or whatever that got injected into the mix somewhere along the way and became gospel; thus, those of us who need such services to keep from getting worse (a reasonable goal, if you’re in that situation) should have access to them, right?

Right; now think about that, then say, “Wow!”

The true wonks among us (or the few of us who can actually remember something I wrote last November) may be recalling this as the “Jimmo Settlement,” and correctly so. When last we left Jimmo, it was securely in the hands of federal District Court, awaiting a decision as to why something that was never in the Medicare law got into the Medicare law. Apparently, the federal District Court judge was not amused and has agreed to get rid of something in Medicare law that was never in Medicare law.

We like that. Why do we like that? Well, let’s try a little Q&A:

*”Skilled services” — Does that mean “…only in a nursing home?” No, it could mean at home, outpatient OR in a skilled nursing facility.

*Will this only apply to certain diseases, diagnoses or conditions? No. It applies to any Medicare beneficiary who requires “skilled services” to keep from getting worse.

*Will this add to the number of days that Medicare will pay for in a nursing facility? Good question! But I’m sorry to say “no,” because the famous “100 days” is specified in Medicare law (alas), but it does change how you might qualify for same.

*Won’t this just cost Medicare (which is, of course, us) more and make this whole “healthcare thing” worse? Ooohh, you’re good. Well, we shall see, but a study was done through the Veterans Administration model where people had access to services like this and it appeared that it actually cost less, because hospitalizations and nursing home costs went down. Why?

Well, because if we have access to what we need, when and where we need it, we tend not to get worse and cost more, which seems to border on “intuitive.”

So, the judge has approved the settlement and has ordered the Centers for Medicare & Medicaid services to revise its “Medicare Benefit Policy Manual,” along with numerous other non-existent policies, guidelines and instructions and to develop and implement a nationwide education campaign to inform us all of what is now true.

I have no idea how long that will take, but here’s something I do know:

These “new” standards apply now — right now. Today.

In fairness, it is entirely possible that local healthcare providers may (a) not know this, and/or (b) be more-than-a-little gun-shy of doing anything Medicare-related that isn’t clearly specified in a manual the size of New Hampshire – I understand that. I also understand that “Mrs. Jones” needs what she needs when she needs it, and she may well need it now, so…

… If you or somebody you like is being denied Medicare coverage based on the now non-existent “improvement standard,” you can go to http://www.medicareadvocacy.org/take-action/self-help-packets-for-medica... and get some good info on how to fight back, remembering that healthcare providers aren’t the “enemy.”

I’m not trying to pretend that this will be easy, because I have yet to encounter anything in healthcare or health insurance that is “easy,” but this is your life, and you have a right to it.

In my world, not getting worse is getting better!

Mark Harvey is the director of Senior Information and Assistance for Olympic Area Agency on Aging. He can be reached at harvemb@dshs.wa.gov or 532-0520 in Aberdeen, (360) 942-2177 in Raymond or (360) 642-3634. FACEBOOK: Olympic Area Agency on Aging-Information & Assistance.