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By: Julieanne E. Steinbacher, Esquire

The most feared words to a nursing home resident or an individual receiving outpatient care or in-home care is that his or her Medicare coverage is ending. Providers are only required to give a two day notice to the Medicare beneficiary, and the news of coverage ending often comes as a surprise. This is especially true upon admission to a skilled nursing facility, as it is presented that he or she will receive up to 100 days of Medicare coverage. The key words are up to 100 days. Unfortunately, generally, this is not the case as coverage typically ends much sooner.

Fortunately, on January 24, 2013, there was a breakthrough with Medicare coverage, based on the case, Jimmo v. Sebelius. The Jimmo v. Sebelius lawsuit was brought forth on behalf of Medicare beneficiaries and organizations representing Medicare beneficiaries that had been denied coverage based on their conditions.

The Jimmo agreement is a critical step in moving forward with Medicare coverage. Until now, Medicare coverage ended when the beneficiaries no longer required “skilled care” or it had been determined that the Medicare beneficiaries would not improve from continuing services. Through the Jimmo agreement, Medicare coverage is now available for beneficiaries requiring services to maintain their condition, not just to improve their condition.

The Jimmo settlement is retroactive to January 18, 2011, the date the suit was filed. Any Medicare beneficiaries who received care in a skilled facility, in their home, or on an outpatient basis, and were denied coverage prior to their 100 days ending, may be eligible for a review of the denial.

The Centers for Medicare & Medicaid Services (CMS), has indicated that they are moving forward with implementing the appropriate changes and providing the proper coverage to Medicare beneficiaries. This could take some time; however, anyone who feels that he or she has been unjustly cut from Medicare benefits from January 18, 2011, through January 24, 2013, should contact The Centers for Medicare & Medicaid Services for further instruction. From January 24, 2013, moving forward, any Medicare beneficiaries that are denied benefits should appeal this decision with the provider of their coverage, such as the nursing facility or care provider.