Office for the Aging


Proposed lawsuit settlement ensures that disabled and chronically ill people have access to rehabilitative services

October 24, 2012 - The U.S. Department of Health and Human Services last week filed a proposed settlement in the class-action lawsuit, Jimmo vs. Sebelius, which challenged the long-standing "improvement standard", which the lawsuit contends illegally denies Medicare benefits for a range of skilled nursing and home health services.

Medicare, and most private insurance in general, often requires people to demonstrate that they can improve in order to get coverage. That meant that many people with chronic medical conditions such as multiple sclerosis, Parkinson's disease, stroke, paralysis and a host of other medical conditions could not get reimbursement for things such as home health care, since their condition was not expected to improve.

If the judge approves the proposed agreement(External Link), it would allow thousands of Medicare beneficiaries in New York and across the nation with disabilities or chronic conditions to qualify for Medicare benefits for physical, speech and occupational therapy, and skilled nursing services that the program wouldn't pay for previously.

The lawsuit was filed in district court in Burlington, Vermont in January 2011 by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four residents of Vermont, Maine, Rhode Island and Connecticut and five health organizations: the National Multiple Sclerosis Society; the Parkinson's Action Network; the Paralyzed Veterans of America; the National Committee to Preserve Social Security and Medicare; and the American Academy of Physical Medicine and Rehabilitation.

More than 5 million Americans are living with Alzheimer's disease, a progressive and fatal degenerative disease that today has no cure. Most individuals with Alzheimer's are Medicare beneficiaries age 65 and older and are high users of health care and long-term care services. Since Alzheimer's disease is progressive in nature, most individuals affected by the disease are unlikely to improve. However, rehabilitative services, including speech, occupational and physical therapy, can help those with Alzheimer's maintain their current function.

Older people with Alzheimer's disease and other dementias have more skilled nursing home stays and home health care visits than other older people without dementia. According to the Alzheimer's Association's 2012 Alzheimer's Disease Facts and Figures report, in 2008 there were 349 skilled nursing facility stays per 1,000 Medicare beneficiaries compared with 39 stays per 1,000 beneficiaries without these conditions. The same year, 23 percent of Medicare beneficiaries with Alzheimer's and other dementias had at least one home health visit, compared with 10 percent of Medicare beneficiaries without these conditions. If individuals with Alzheimer's do not have these necessary services, it can hasten their decline and accelerate the need for more expensive services, such as hospitalizations or placement in a nursing home.

The changes would apply to all people over the age of 65 who have both traditional Medicare coverage or are covered under a private Medicare Advantage plan. It would also cover those under 65 who qualify for the program due to a disability.