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No improvement? Medicare will pay

By Jennie L. Phipps · Bankrate.com
Thursday, November 1, 2012
Posted: 12 pm ET

If you're a Medicare recipient whose claims have been denied because your condition isn't improving as a result of treatment, last month's settlement of a lawsuit against the federal government's Centers for Medicare & Medicaid Services will change that.

This is a real retirement planning victory for many.

Medicare has for decades operated under the "improvement standard," refusing to pay for rehabilitation services for people living in retirement whose conditions were chronic and whose treatment was for maintenance, not improvement. People with multiple sclerosis, Alzheimer's disease, Lou Gehrig's disease (ALS), Parkinson's disease and paralysis were particularly affected by this standard.

About two years ago, Vermont Legal Aid and the Center for Medicare Advocacy brought suit on behalf of Glenda Jimmo, 76, who had been blind since age 19 and was confined to a wheelchair because her leg had been amputated. Medicare denied coverage for skilled nursing services in her home because it said she was unlikely to improve.

The suit argued that the standard was a convenient rule of thumb among administrators and wasn't supported by Medicare law. A judge agreed.

The agreement is retroactive to Jan. 18, 2011, but you may be eligible for reimbursement for services denied before that if you received an initial determination that had not yet become "final and nonappealable" by that date.

The Center for Medicare Advocacy says it may take a year for Medicare to clarify its guidelines, but anyone who believes that they are due benefits as a result of this settlement should use the settlement information on the Center for Medicare Advocacy's website to push for payment.

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