Disabled Vt. Senior Wins Medicare Coverage After 2nd Lawsuit

A disabled senior with serious health problems who successfully challenged Medicare for denying her home health care coverage has racked up another win against the government.

In her latest federal lawsuit filed in June, Glenda Jimmo, 78, argued Medicare should have paid for the nursing care and other skilled services she received at her home during 2007. On Wednesday, Medicare officials agreed, invalidating an April ruling that she was not entitled to coverage because her condition had stabilized and she was not improving.

“I won,” said Jimmo, who is receiving rehab therapy at a Vermont nursing home and hopes to return home soon.  “I’m very pleased. It makes me feel America is still in good shape.”

The settlement doesn’t mention that Jimmo was the lead plaintiff in a 2011 class-action lawsuit seeking to eliminate the so-called “improvement standard” as a criteria for Medicare coverage. In the 2012 settlement that bears her name, the government agreed that improvement was not required and allowed many Medicare beneficiaries with chronic conditions and disabilities to appeal claims that had been denied because they were unlikely to get better.  Jimmo is legally blind and has a partially amputated leg due to complications from diabetes.

“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, which filed the original class action lawsuit with Vermont Legal Aid and negotiated both settlements.  “It’s helpful to know that people will get a fair shot for an appeal because if Mrs. Jimmo couldn’t, who could?”

After the 2012 settlement, Jimmo was one of the first seniors to seek a review. But Medicare’s highest appeals panel, the Medicare Appeals Council, upheld the original denial of her claims in April. Her attorneys went back to federal court, claiming the panel did not follow the principles laid out in the settlement.

Medicare officials agreed Wednesday that the Medicare Appeals Council’s denial “shall have no remaining force or effect.”  Medicare will now pay Jimmo’s home health agency nearly $12,000, as well as her attorney fees.

“Requiring improvement and denying coverage to people with chronic conditions was a serious problem that has affected many thousands of people for many, many years,” said her attorney Michael Benvenuto, director of Vermont Legal Aid’s Medicare Advocacy Project.

A Medicare spokeswoman Thursday took care to note that Wednesday’s settlement applied only to Jimmo and does not signify a change in Medicare coverage determinations.

Stein acknowledged that only a Medicare contractor can issue what is known as a formal “Medicare coverage determination.” But because Jimmo’s claim was settled through a federal court instead of  the regular Medicare appeals system, it was paid in full, she said. And since the settlement also removed the appeals council denial, Stein added, Jimmo should not  face future coverage barriers due to a lack of improvement.

This story was updated to include comments from Medicare officials that came only after the story was published and a response from Judith Stein.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Categories: Aging, Cost and Quality, Medicare