Understanding Jimmo vs. Sebelius

In this article...
  • As a result of the landmark decision in Jimmo v. Sebelius, Medicare policy now clearly states that coverage decisions for skilled care (nursing care or therapy) cannot hinge solely on whether a patient is improving or expected to improve. Understanding this case may help you fight inappropriate Medicare coverage denials. Learn how.

If you need skilled care (nursing care or therapy) in a skilled nursing facility, Medicare will generally cover this care under your Medicare Part A benefits after you have a qualifying hospital stay.

This may be true regardless of whether your health improves or whether you doctor expects it to improve. Why? An important legal decision made in the case of Jimmo vs. Sebelius ensures that Medicare can’t deny coverage based solely on your ability to improve.

Understanding this important legal decision can help you fight potential denials if they occur.

Some Medicare Supplement plans can fully or partially cover your Medicare out-of-pocket costs when you receive covered skilled nursing care. Compare Medicare Supplement plans – also called Medigap plans – online for free, with no obligation to enroll, and find a plan where you live that pays for skilled nursing care.

What Is the Jimmo vs. Sebelius Summary?

Jimmo vs. Sebelius was a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who were denied Medicare coverage for skilled care on the basis that they were not improving or did not demonstrate a potential for improvement.

The lead plaintiff (Glenda Jimmo), who was blind and who had undergone a leg amputation due to complications from diabetes and other conditions, required a wheelchair and home health nursing. However, Medicare denied coverage for her home care on the grounds that she would not get better.

As a result of the Jimmo v. Sebelius case that was settled on January 24, 2013, Medicare policy now clearly states that skilled care coverage does not depend solely on the presence of absence of a beneficiary’s potential for improvement. Even if full recovery or medical improvement is not possible, patients may still require skilled care to maintain their current health or prevent or slow additional deterioration of their conditions. 

This means your Medicare contractor cannot deny coverage solely because of an underlying condition that won’t get better (e.g., multiple sclerosis, paralysis, ALS, diabetes, or Parkinson’s disease). The decision also applies to home health services, outpatient therapy services (physical, occupational, and speech), and nursing and therapy in inpatient rehabilitation hospitals.

Does Jimmo v. Sebelius Mean Medicare Will Cover My Skilled Care Services 100% of the Time?

No, Medicare determines coverage based on an individualized assessment of your medical condition (provided by your doctor) and other criteria. The Jimmo vs. Sebelius Settlement Agreement simply means Medicare must look at the big picture – not just whether your health will improve.

Note that Medicare may not cover your skilled care if you’re no longer improving (or not expected to improve) and skilled care is also no longer necessary to maintain your current condition or prevent or slow additional deterioration.

When Medicare coverage of your skilled nursing facility stay is ending because it’s no longer medically reasonable and necessary or is considered custodial care (i.e., non-medical care that can reasonably and safely be provided by non-licensed caregivers), you’ll get a written notice called the Notice of Medicare Non-Coverage (NOMNC). 

Even if Medicare Part A and/or Part B covers your skilled nursing care or therapy, you'll typically be responsible for meeting a deductible and coinsurance or copay amounts. Some Medicare Supplement plans can fully cover those out-of-pocket Medicare deductibles and copays.

Does the Jimmo Settlement Agreement Apply to Beneficiaries of Medicare Advantage Plans?

Yes, Medicare Advantage (Medicare Part C) plans cover the same Part A and Part B benefits as Original Medicare, and they must comply with the Jimmo vs. Sebelius Settlement Agreement. Some Medicare Advantage plans may also cover benefits that help you age healthy and comfortably at home, such as home meal delivery, home upgrades like bathroom grab bars and more. 

What if Medicare Denies My Coverage?

You may be able to request a re-review of your denied claim. This Jimmo vs. Sebelius toolkit compiles various references into one document you can reference to support your argument. 

Where can I learn more about the Jimmo vs. Sebelius case?

You can read various Jimmo vs. Sebelius FAQs on Medicare.gov, the official government website for Medicare. You can also call 1-800-MEDICARE.

To learn more about how a Medicare Supplement plan could help save you potentially high out-of-pocket Medicare costs for your skilled nursing care or therapy, compare plans online or call to speak with a licensed insurance agent.

About the Author

Lisa Eramo is an independent health care writer whose work appears in the Journal of the American Health Information Management Association, Healthcare Financial Management Association, For The Record Magazine, Medical Economics, Medscape and more.

Lisa studied creative writing at Hamilton College and obtained a master’s degree in journalism from Northeastern University. She is a member of the American Health Information Management Association, American Academy of Professional Coders, Society of Professional Journalists, Association of Health Care Journalists and the American Society of Journalists and Authors.

Lisa currently resides in Cranston, Rhode Island with her wife and two-year-old twin boys.

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