Clarification of Medicare Standard for Skilled Care Improvement Not Required

The Center for Medicare Advocacy (CMA) has achieved a significant victory on behalf of Medicare beneficiaries nationwide. For decades, necessary rehabilitation services have been denied on the basis that an individual’s condition had “plateaued.” Individuals were told that skilled services are only covered by Medicare if the individual was improving. If the individual’s condition was stable, chronic, or the services were for "maintenance only," they would not be covered. As noted by CMS, this denial of services has had “a particularly devastating effect on patients with chronic conditions such as Multiple Sclerosis, Alzheimer's disease, ALS, Parkinson's disease and paralysis.”

The CMA challenged this erroneous interpretation of the Medicare Benefit Policy Manual in a lawsuit, Jimmo v. Sebelius, filed in federal District Court in Vermont in January of 2011. The settlement with the Centers for Medicare & Medicaid Services (CMS) was announced in October of 2012 and approved by the Court in January.

For thorough details, see this article on the CMA’s web site:

Here are excerpts from the article:

Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve." Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual’s conditon, or prevent or slow their decline.

The Settlement Agreement standards for Medicare coverage of skilled maintenance services apply now. In fact, the government insists that it is only clarifying what has always been the Medicare coverage standard and that the Settlement does not change Medicare laws or regulations. The law never suported the requirement that people improve in order to get Medicare. Accordingly, health care providers should implement the maintenance standard now. Patients should discuss the Medicare maintenance standard with their providers to determine if it is applicable to them.

The Jimmo Settlement Agreement applies to skilled maintenance services provided at home or as an outpatient, or only to nursing home coverage.

The Jimmo Settlement Agreement is retroactive and goes back to the date the case was filed, January 18, 2011. The Agreement establishes a process called "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) because of the Improvement Standard that became final and non-appealable after January 18, 2011. When the government completes revision of its policy and guidelines, and educates Medicare decision-makers, individuals will be able to get a re-review of these claims.

This is such an important decision for so many of the individuals and families who work with Maine Elder Law Firm. If you think you or a loved one is being denied Medicare coverage of skilled services, please contact us.

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