HHS Provided Inaccurate Education after the Improvement Standard Ended, Judge Rules

September 9, 2016 | Aging Services Risk Management


​In failing to provide accurate information in its educational campaign regarding the maintenance coverage standard—which holds that Medicare covers skilled nursing facility, home health, and outpatient therapy services that are needed to maintain the beneficiary's current condition or prevent or slow further deterioration—the U.S. Department of Health and Human Services (HHS) has breached the settlement agreement reached in Jimmo v. Sebelius, according to an August 17, 2016, ruling by the U.S. District Court for the district of Vermont. The lawsuit that the settlement agreement resolved had challenged the so-called improvement standard, under which HHS allegedly reimbursed only for care, treatment, or services that led to improvements in beneficiaries' conditions (see the February 1, 2013, Issues in Continuing Care Risk Management). The plaintiffs alleged that HHS's revisions to the Medicare Benefit Policy Manual were inadequate and that HHS's educational campaign was "deficient."

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