Skilled nursing care and skilled therapy services for beneficiaries who need skilled care to maintain function or to prevent or slow decline is covered by Medicare. That is the message of reminders issued by the Centers for Medicare & Medicaid Services (CMS) to Medicare providers as well as to Medicare Administrative Contractors.[1] CMS disseminated the information in its December 2, 2021 MLN Connects Newsletter.[2] Furthermore, CMS directed providers and contractors to visit the Jimmo Settlement Agreement webpage for further details.
The CMS statement follows:
The Center for Medicare Advocacy and Vermont Legal Aid brought the Jimmo v. Sebelius class action lawsuit on behalf of beneficiaries who were being denied Medicare coverage for skilled care on the basis that they were not improving or did not demonstrate potential for improvement. In 2013, the federal district court approved a settlement agreement that confirmed Medicare coverage should be determined by a beneficiary’s need for skilled care, not the individual’s potential for improvement; Medicare covers skilled care to maintain an individual’s condition or slow decline.[3] Essentially, improvement or progress is not necessary as long as skilled care is required. The Jimmo standards apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, for care in Inpatient Rehabilitation Facilities/Hospitals.[4]
Check out a collection of Jimmo resources from the Center for Medicare Advocacy here .
[1] CMS. MLN Connects® Newsletter (2021-12-02-MLNC). CMS. (December 2, 2021). Available at: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-12-02-mlnc#_Toc89267937
[2] CMS. MLN Connects® Newsletter. CMS. (n.d.). Available at: https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive
[3] CMA. Jimmo v. Sebelius Factsheet: Medicare Skilled Nursing Facility Coverage Does Not Require Improvement. Center for Medicare Advocacy. (May 20, 2021). Available at: https://medicareadvocacy.org/jimmo-v-sebelius-factsheet-medicare-skilled-nursing-facility-coverage-does-not-require-improvement/
[4] CMA. Improvement Standard and Jimmo News. Center for Medicare Advocacy. (May 15, 2020). Available at: https://medicareadvocacy.org/medicare-info/improvement-standard/