Medicare Does Not Require Improvement

elderly man receiving nursing home care

Many health care providers believe that Medicare will only provide coverage if a patient is making “progress.”  For most of my clients who are in nursing homes, the facility normally informs our client’s family that in order to maintain Medicare coverage, the individual must be making progress.  Otherwise, the nursing home facility is under the belief that if the individual has reached a plateau, then Medicare will terminate.

The applicable federal statute does not require “progress” in order to continue Medicare coverage.  As long as the health care services are being provided to maintain the individual’s well-being, or at least prevent the resident’s well-being from diminishing, then Medicare should cover those services.

I am very pleased to confirm that as a result of a class action lawsuit that was filed against the federal government, a settlement was eventually reached in federal court.  According to the terms of the settlement agreement, Medicare is not allowed to terminate coverage to a patient who has stopped improving.

The Center for Medicare Advocacy and the Vermont Legal Aid filed a class action lawsuit against the federal government in Federal Court.  This case is known as Jimmo v. Sebelius.  The objective of this class action lawsuit was to stop the government’s use of the improvement standard.  The federal government tried to dismiss the case.  The court refused to dismiss the case and as a result, a settlement was eventually entered into by Medicare and the plaintiffs in the class action lawsuit.

The terms of the settlement agreement require that Medicare revise the Medicare Manual to make it clear that Medicare coverage of skilled nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement.”  Rather, Medicare coverage is based upon whether or not the individual needs “skilled” care, even if this care will simply maintain the beneficiary’s current condition, or at least slow further deterioration.

Unfortunately, many nursing homes are not complying with federal law and insist that the resident show progress in order to keep Medicare coverage.  The Center for Medicare Advocacy encourages people to appeal if they are told by a nursing home that Medicare will not cover skilled care because they are not improving.