MONTPELIER — A federal lawsuit brought in Vermont is bringing about a change in national Medicare practices that advocates say will improve coverage for people in long-term care.
Vermont resident Glenda Jimmo was lead plaintiff in the case that challenged what some providers perceived as Medicare’s requirement that patients being treated in settings ranging from nursing homes to home health had to be improving in order for their coverage to continue.
Several national advocacy groups went to bat for Jimmo in a lawsuit that sought a new standard clarifying that care could continue even if was only geared toward preventing the patient’s condition from getting worse.
Now the federal Centers for Medicare and Medicaid Services has issued new rules following a court settlement approved by Vermont U.S. District Court Judge Christina Reiss.
The Center for Medicare Advocacy and other groups argued in the suit that many providers had adopted a rule of thumb that a patient needed to be improving for coverage to continue. A statement issued by the federal agency with new Medicare rules last week said that was never the case.
“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,” it said.
“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,” it added.
Judith Stein, executive director of the Center for Medicare Advocacy, said in a statement Monday that the new rules “should go a long way to ensuring that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline — not just for improvement.”
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