For many disabled people, Medicare did not cover their skilled nursing expenses due to the type of condition they had and their ability to improve. Until recently, Medicare did not cover medical expenses related to ongoing care needed just to maintain their condition, not improve it. It took a landmark lawsuit case and a strong, disabled woman by the name of Glenda Jimmo heading it to make the change possible.

Jimmo v. Sebelius

The case that has made this change was started in part by Glenda Jimmo, a disabled woman with diabetes that has had a challenging life. Blind since she was 19, her disease has also taken one of her legs below the knee and left her in a wheelchair. Since her condition was not deemed improvable, many nursing needs could not be covered under Medicare.

The lawsuit was not just representing Jimmo, but a class-action suit representing the Center of Medicare Advocacy (CMA) on behalf of a class of Medicare beneficiaries and also the National Multiple Sclerosis Society, the Paralyzed Veterans of American, the Parkinson’s Action Network, and the National Committee to Preserve Social Security and Medicare. The case was refuting the use of the Medicare “improvement standard” which denied care to people needing ongoing care for there medical conditions due to the fact that the care would not improve their conditions.

What The Changes Will Mean

For many disabled, this settlement will mean access to coverage for skilled nursing facility care, home health care, and outpatient therapy services that were denied under the “improvement standard” rule. No longer will their ability to improve be a factor in whether they can get the skilled care they need. Care now is classified under maintaining or prevention of deterioration of their condition.

Many disabled now will be able to be admitted for nursing home care or receive home or outpatient care. Even though the settlement has not had final approval by the courts, the terms are in place and CMA has encouraged anyone who was denied benefits due to the improvement standard or has need of skilled nursing care to apply for benefits. All claims that were denied on this basis before the case was submitted in January 2011 will also be re-examined to see if they should qualify for benefits.

This is a huge leap forward for skilled care that is needed by many in the disabled community. Although there are limitations to the benefits, it is a definite improvement on a system that was broken with no clear indication as to why these people were denied benefits in the first place.

http://www.reuters.com/article/2012/10/27/us-column-miller-idUSBRE89Q0CN20121027