In 2013, the Center for Medicare Advocacy reached a settlement with the Centers for Medicare & Medicaid Services (CMS) in the national class action case, Jimmo v. Sebelius. The Settlement, reaffirmed in 2017, confirmed that beneficiaries do not have to improve to qualify for Medicare coverage of necessary care: the key to coverage is whether skilled care is required. Further, determinations must be based on an individualized assessment of each person’s condition and whether they meet coverage criteria. CMS, the federal Medicare agency, reiterates this and more in the Jimmo section of its website.
The Jimmo principles apply to home health care, nursing home care, outpatient therapies, and, to a certain extent, care in inpatient rehabilitation facilities/hospitals. The Center for Medicare Advocacy seeks to monitor misinformation and coverage denials for necessary care that is based on a version of an improvement standard.