Two weeks ago, a good friend of mine was giving me an update on her husband who is in a facility receiving Medicare-covered services. He was not doing well, and to make matters worse, she had been told that Medicare coverage would not continue since he was not improving.
“What?!” I said. The standard for Medicare coverage is not whether the patient is improving, but rather whether he needs the care to maintain his condition or to keep from deteriorating.
In fact, this false “improvement” standard has been so pervasive that the Centers for Medicare & Medicaid Services (CMS) actually litigated the issue in 2013. This litigation resulted in the Jimmo Settlement Agreement (January, 2013). That agreement clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met). The Agreement required revisions in relevant program manuals used by Medicare contractors. They were required to be reworded for clarity, so as to reinforce the intent of the policy.
Many providers have erroneously believed that the Medicare program covers nursing and therapy services only when a beneficiary is expected to improve.
The Jimmo Agreement did not CHANGE Medicare standards for coverage; it simply clarified the erroneous idea that improvement was required to continue care that met its other standards.
Ten years later, and the issue is still coming up. My friend is a lawyer. She was totally unaware that her husband was about to be denied coverage because of a false requirement. She called me this week ebullient. “I won the appeal! Thanks for telling me about Jimmo!”
Again, “In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” That need can be based on whether the patient must have the therapy to maintain his current condition or to prevent or slow further deterioration.
A decade later, patients still encounter problems related to the mythical “improvement standard.” The Center for Medicare Advocacy has recently updated its fact sheet to outline Medicare beneficiary rights when it comes to Medicare coverage in a skilled nursing facility.