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Medicare Settlement Update

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Previously, Medicare beneficiaries, particularly those with long-term or debilitating conditions and those who need rehabilitation services were subject to the Improvement Standard. The improvement standard resulted in Medicare coverage being denied on the grounds that ones condition was stable, chronic, not improving, or that the necessary services were for maintenance only.

The lawsuit, Jimmo v. Sebelius was brought on behalf of a nationwide class of Medicare beneficiaries to challenge the use of the Improvement Standard. On November 20, a settlement agreement was reached that changed the Medicare reimbursement policy. Now, no longer will Medicare reimbursement hinge on whether an individual can prove their condition will improve. One must, from a baseline, need skilled care in order to receive coverage. This has been an ongoing concern for the paralysis community and we are excited to hear of the judgment.

What this means for those with disabilities is that if a patient needs skilled care and he or she meets the other requirements for Medicare coverage, that patient will be covered, regardless of whether or not the patient’s condition is improving. This will have an extraordinary impact on the disability community, providing significant financial relief and necessary services that patients might not receive otherwise.

This is an important development for the paralysis community. On January 24 the court will hold a Fairness Hearing, to determine whether the settlement is fair, reasonable, and adequate. After this hearing, it is hoped the judge will issue an order to permanently approving the settlement. Following the judge’s ruling CMS will revise the Medicare Benefit Policy Manual to ensure that beneficiaries receive coverage despite their conditions.

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Continue Christopher Reeve's LegacyPhoto by Timothy Greenfield-Sanders