In 2013, the Center for Medicare Advocacy and Vermont Legal Aid, along with additional counsel provided by Wilson Sonsini Goodrich & Rosati, settled a lawsuit with the Medicare program (the named defendant, Katherine Sebelius, was the Secretary of Health and Human Services at the time) challenging the so-called “improvement standard.”
As a result of the case, the Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits in order to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other coverage criteria are met), the Medicare program covers such services and coverage cannot be denied based on the absence of potential for improvement or restoration.
Ten years later, therapists and providers continue to learn best practices for engaging patients in a skilled maintenance level of care.
Let’s review some of the top questions for clarity:
Question:
Are therapy services available under Medicare only for patients who are improving or expected to improve?
Answer:
No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing facilities, home health and outpatient therapy, when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration.
Question:
What qualifies a patient for therapist-provided maintenance services under the Medicare benefit?
Answer:
Since maintenance services are considered skilled care, the patient must meet the setting-specific qualifying criteria outlined in the law, regulations, and Medicare Benefit Policy Manual. Once those criteria have been confirmed, the qualified therapist will, after completion of a thorough assessment of the patient, select the focus of care in collaboration with the physician. If the patient is currently at a point where material improvement is not expected and decline is probable without skilled therapy care, a maintenance course of care may be developed and implemented.
Question:
Does Jimmo apply only to specific medical conditions such as Multiple Sclerosis or Parkinson’s disease?
Answer:
No. The settlement is not limited to any particular condition or disease. It applies to any Medicare patient who requires skilled nursing or skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s further decline or deterioration, regardless of the patient’s underlying illness, disability or injury. The settlement is not limited to people with chronic conditions and applies equally, for example, to patients who had a stroke. The fundamental issue for coverage under the standard clarified by Jimmo is whether the patient needs professional services to maintain function or to prevent or slow decline or deterioration.
Question:
Does the Jimmo settlement apply to patients who have dementia?
Answer:
Yes. Dementia is not a disqualifying condition for Medicare coverage. If the patient needs skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s decline or deterioration, Medicare covers the therapy services, as long as all other coverage criteria are met. Skilled professional therapists are trained to work with patients who have dementia.
Question:
What qualifies a patient for discharge when receiving maintenance therapy?
Answer:
A patient receiving therapy as outlined in the law, regulations and Medicare Benefit Policy Manual, is appropriate for discharge from skilled service when the patient no longer requires the skills of an occupational therapist, physical therapist, and/or speech-language pathologist.
“Skilled” services are those that can only be provided by a qualified therapist, due
to the complex nature of the needed therapy procedures and/or the patient’s special medical complications that require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled.
Ready to learn more?
The Center for Medicare Advocacy is hosting a virtual meeting Sept. 27 to hear from advocates, providers, beneficiaries and others who will discuss practical tips and strategies for obtaining medically necessary services pursuant to the Jimmo settlement.
Register here to join the conversation and celebrate this monumental case with others in the industry!
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty; is a member of the American Medical Association’s (AMA) Digital Medicine Payment Advisory Group (DMPAG), and an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected]
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