Advocates sue Medicare over home service claims denials

Attorneys for Vermont Legal Aid and the Center for Medicare Advocacy are suing the federal government over accusations that it wrongly denied home health services to Medicare beneficiaries.

The class action lawsuit alleges that the Secretary of Health and Human Services, who is responsible for the Centers for Medicare and Medicaid Services, repeatedly refused to pay for home health services for beneficiaries on the basis that they are not homebound, even when Medicare has previously determined that they are.

A CMS spokeswoman said she could not comment on pending litigation.

The suit was filed Dec. 19 in U.S. District Court in Burlington on behalf of Vermont residents Marcy Ryan and John Herbert. The suit is a regional class action filing covering New England and New York.

Medicare rules require that the federal health program for the elderly and disabled cover home health services, including skilled nursing and therapy services, but those services are only available to beneficiaries who are homebound.

The lawsuit seeks to stop Medicare from “repeatedly denying coverage” after a Medicare administrative judge has ruled that the beneficiary is homebound, according to a statement from Vermont Legal Aid.

The plaintiffs are disabled and wheelchair bound. Medicare administrative judges have found both to be homebound on several occasions when they appealed the denial of home health services. Even after judges ruled that they were homebound, the contractors that administer benefits for Medicare continued to deny their claims for services, according to the statement.

“Medicare policies state that once plaintiffs have been found to be homebound by a Medicare judge, they should be presumed to be homebound for Medicare coverage, unless there is evidence that they have improved,” said Legal Aid attorney Rachel Seelig in a statement. “It is wrong for Medicare to continually and repeatedly deny them coverage.”

The lawsuit seeks an order from the U.S. District Court compelling Medicare “to follow its own rules” and respect the decisions of its judges, according to the statement.


Morgan True

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