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 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.
鈥淚 won,鈥� said Jimmo, who is receiving rehab therapy at a Vermont nursing home and hopes to return home soon.聽 鈥淚鈥檓 very pleased. It makes me feel America is still in good shape.鈥�
The settlement doesn鈥檛 mention that Jimmo was the lead plaintiff in a 2011 class-action lawsuit seeking to eliminate the so-called 鈥渋mprovement standard鈥� as a criteria for Medicare coverage. In the 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.聽 Jimmo is legally blind and has a partially amputated leg due to complications from diabetes.
鈥淭his should give hope to other people who are going through the Medicare appeals process,鈥� said Judith Stein, executive director of the Center for Medicare Advocacy, with Vermont Legal Aid and negotiated both settlements.聽 鈥淚t鈥檚 helpful to know that people will get a fair shot for an appeal because if Mrs. Jimmo couldn鈥檛, who could?鈥�
After the 2012 settlement, Jimmo was one of the first seniors to seek a review. But Medicare鈥檚 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鈥檚 denial 鈥渟hall have no remaining force or effect.鈥澛� Medicare will now pay Jimmo鈥檚 home health agency nearly $12,000, as well as her attorney fees.
鈥淩equiring聽improvement and denying coverage to people with chronic conditions was a serious problem that has affected many thousands of people for many, many years,鈥� said her attorney Michael Benvenuto, director of Vermont Legal Aid鈥檚 Medicare Advocacy Project.
A Medicare spokeswoman Thursday took care to note that Wednesday鈥檚 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 鈥淢edicare coverage determination.鈥� But because Jimmo鈥檚 claim was settled through a federal court instead of 聽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 聽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.