Jimmo settlement: Will effects be widespread?

Glenda Jimmo will receive Medicare coverage for previously denied claims for skilled home health maintenance care benefits under the terms of the settlement (PDF) of a federal lawsuit brought against the U.S. Department of Health and Human Services (HHS). The settlement clarifies that Medicare coverage of nursing and therapy services is based on a beneficiary’s need for skilled care, not on his or her ability to improve.

The 78-year-old legally blind Vermont woman, whose one leg is partially amputated, first came into the public eye in 2007 when the Centers for Medicare & Medicaid Services (CMS), part of HHS, denied coverage for the care. In 2012, the settlement of a national class action suit in which she was the lead plaintiff, Jimmo v. Sebelius, changed the government’s practice of denying skills maintenance care to people who did not meet an “improvement standard.” The most recent lawsuit, Jimmo v. Burwell, was filed in June after the Medical Appeals Council in April denied Jimmo coverage for the home care she had received in 2007, despite the agreement reached in the earlier case.

“The resolution of this federal care completely vacates the Appeals Council denial for her skilled maintenance home care,” Judith Stein, executive director of the Center for Medicare Advocacy, said in a press release. Stein was one of the attorneys who brought the aforementioned class action suit. “The maintenance home care she received will now be paid in full. And coverage for similar skilled maintenance care may also be available,” she added.

HHS will pay more than $11,000 to Jimmo’s home health agency, Addison County Home Health and Hospice, plus $4,400 in attorneys’ fees.

“This settlement should send the message that denying Medicare coverage for a chronic condition is wrong,” said Jimmo’s attorney, Michael Benvenuto, who is director of the Vermont Legal Aid Medicare Advocacy Program. One media account notes that CMS considers the settlement to apply only to Jimmo’s case, not to all beneficiaries.

In a blog posting, Dan Ciolek, senior director of therapy advocacy at the American Health Care Association, says that the settlement means:

• Those with chronic conditions can benefit from maintenance therapy as a covered Medicare benefit;
• The health of those who have chronic health problems can decline without maintenance therapy, and such decline can lead to more expensive inpatient services;
• Those with chronic health issues whose health has declined recently can benefit from care in a skilled nursing facility and then return to their homes.