posted Dec 20, 2013, 6:27 AM by Frank Baskin   [ updated Dec 20, 2013, 6:31 AM ]
Medicare has established a new standard for community and nursing home skilled care. Maintaining current level of care or preventing deterioration are now standards along.....PLEASE CLICK TITLE FOR MORE....with Improvement as a criteria. It is all effective as of 1/6/2014.See below for more information.

Medicare Policy to Ensure Coverage for Skilled Maintenance Care

The Centers for Medicare & Medicaid Services (CMS) published revisions to the Medicare Benefit Policy manual on December 6th to clarify that skilled care and skilled therapy can be covered for conditions that will not improve.  The revisions will become effective January 7, 2014 (marked in red in the following link  These revisions are a direct result of the January 24, 2013 settlement of the Jimmo v. Sebelius case.

The revisions clarify Medicare’s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration.  The need to show improvement has been challenged for decades, and the Medicare revisions are a huge victory for people with Alzheimer’s disease, multiple sclerosis, Parkinson’s disease and other chronic conditions. 

Here’s what you can do:

CMS is starting an Education Campaign to ensure that Medicare determinations are based on the need for skilled care – not on the ability of an individual to improve. 

The Center for Medicare Advocacy (CMA) below provides additional details.

Improvement Standard Update: CMS Revises Medicare Policy to Ensure Coverage for Skilled Maintenance Care

The Center for Medicare Advocacy is pleased to announce that the Medicare Policy Manuals have been revised pursuant to the Jimmo vs. Sebelius Settlement.  The Jimmo case ended a longstanding practice denying Medicare coverage to people who  had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday December 6, 2013. They pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF) [nursing home category], Home Health care (HH), and Outpatient Therapies (OPT). 

As CMS states in the Transmittal announcing the Jimmo Manual revisions: 

No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning. 

As with components of all settlement agreements, the Jimmo revisions are not perfect,” says Judith Stein, Executive Director of the Center for Medicare Advocacy. “But they do make it absolutely clear that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline – not just for improvement.”

Plaintiffs in Jimmo vs. Sebelius are represented by the Center for Medicare Advocacy and Vermont Legal Aid.  Jimmo is a certified national class action lawsuit brought by individual Medicare beneficiaries and national organizations. It was formally settled by the Plaintiffs and Secretary Sebelius on January 24, 2013, when federal Judge Christina Reiss approved the settlement Agreement.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website.  The CMS MLN Matters article is also available on the CMS site under “Downloads.”

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For more details on the Improvement Standard and the Jimmo case, see: