Revisiting Jimmo v. Sebelius and the “Improvement Standard” for Medicare Coverage

If you or a loved one has been receiving Medicare to pay for skilled nursing or therapy care and Medicare suddenly stopped paying, you may want to appeal that decision.  The wrong standard may have been applied to your case.

JIMMO MEDICARE SETTLEMENT AGREEMENT

In 2013, the Jimmo Settlement Agreement profoundly impacted Medicare coverage. Before the Jimmo case, Medicare was cutting off coverage for patients who were no longer showing improvement with skilled nursing or therapy care.  The Jimmo Settlement Agreement required the Center of Medicare Services to revise its manual.  The new standard in the CMS manual was a “Maintenance Coverage Standard.”  This standard applied to the following services:

Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.

Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program.  Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.

Source: https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html

Medicare’s 2016 CORRECTIVE ACTION PLAN

Even though this standard was ordered in 2013, CMS failed to properly educate its organization and related health-care service providers.  In 2016, the plaintiffs in Jimmo went back to court to demand CMS properly disseminate the new standard.  A Corrective Action Plan was ordered requiring CMS to take steps to inform its stakeholders of the new standard.

Today, many Medicare advocacy groups still receive complaints of the improvement standard being relied upon to deny Medicare coverage.  Patients and their families have appeal rights in these situations. They must act quickly to maintain coverage and prevent a private pay or discharge scenario.

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