Even though Medicare agreed in a 2012 settlement to cover skilled care for beneficiaries who are not improving, the continued confusion around the issue has affected the lead plaintiff in the class action that led to the settlement. Glenda Jimmo was required to file another federal lawsuit in order to make sure she received benefits.
Ms. Jimmo, a Vermont resident, is legally blind and has a partially amputated leg due to complications from diabetes. When Medicare refused to cover her treatment because she was no longer improving, Ms. Jimmo filed a class action against the federal government. Under the settlement agreement in Jimmo v. Sebelius, Medicare will cover skilled care as long as the beneficiary needs skilled care, even if it would simply maintain the beneficiary's current condition or slow further deterioration, and the agency pledged to update its policy manual and mount an educational campaign about the policy.
Ms. Jimmo was one of the first people to appeal her Medicare denial after the settlement decision. But in April 2014, Medicare Appeals Council judges denied her benefits again, agreeing with the previous decision that she didn't qualify for benefits because she wasn't improving.
The denial led Ms. Jimmo to file another federal lawsuit in June, claiming Medicare was not following the settlement in Jimmo. This time she was successful. On October 29, Medicare officials invalidated the earlier decision and agreed to pay for her care. “I won,” said Ms. Jimmo. “I’m very pleased. It makes me feel America is still in good shape.”
"This should give hope to other people who are going through the Medicare appeals process," said Judith Stein, executive director of the Center for Medicare Advocacy, who helped negotiate the settlement named for Ms. Jimmo.
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