If the name Glenda Jimmo rings a bell for you, give yourself a pat on the back. In 2011, Jimmo went to court seeking help from the government in paying for her care. At issue was the need for Jimmo to receive physical therapy and other care. Jimmo, who is legally blind needed a partial leg amputation due to complications arising from diabetes. At issue was whether or not Medicare should pay for skilled nursing and home health care to maintain her condition and to reduce complications. The class-action suit against the government sought to broaden Medicare’s criteria which for decades had included an “improvement standard.” That standard allowed patients to be denied coverage based on whether they had reached a plateau and were not expected to get better.
In 2012, the government settled the case and agreed to allow patients to appeal cases in which the improvement standard was used to deny coverage. The settlement required Medicare to rewrite Medicare’s policy manual to clarify the new policy and put processes in place to educate providers, contractors and appeals judges about the change. Jenessa Shagena, a Care Manager with Better Care Management said she still sees claims being denied. Despite the ruling, “It’s no different.” Jimmo was one of the first to appeal her denial of coverage. But, she was denied again because her condition was not improving, a Medicare condition that was supposed to have been eliminated with the settlement.
To read more on the story including where to go to for help if you need to appeal a Medicare decision, read this story from Kaiser Health News.
Update: On Oct. 29, Jimmo’s second case was also settled and she’ll finally be able to have the home maintenance care she received be paid in full. Coverage for similar skilled maintenance may also be available for her. To read more about the final settlement, go here.