NPR logo Medicare Concedes, Agrees To Pay For Woman's Home Health Care

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Medicare Concedes, Agrees To Pay For Woman's Home Health Care

A disabled woman 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 that 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 people 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.

A Medicare spokeswoman 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. And since the settlement also removed the appeals council denial, Jimmo should not face future coverage barriers due to a lack of improvement.