If you, or someone you are helping are informed that Medicare coverage is not available for necessary care because improvement isn’t possible or sufficient, remember – that’s not true. Quote and direct them to the Medicare agency’s own website, CMS.gov, about the Jimmo Settlement.
“Important Message About the Jimmo
Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.
Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (‘skilled care’) are necessary for the performance of a safe and effective maintenance performance of the program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.”
As the Medicare agency recognizes, an “improvement standard” is not to be applied in coverage determinations for skilled maintenance care in a skilled nursing facility, through home health care, or for outpatient therapy. Such care is available as long as the care setting criteria are met. It’s the law!