The Center for Medicare Advocacy is often asked in what care settings the Jimmo Settlement applies. Jimmo applies to skilled care – nursing and therapy (physical, occupational and speech language pathology) – received in a skilled nursing facility, home health care, and on an outpatient basis.
As the Medicare Outpatient Therapy Policy Manual states (Medicare Benefit Policy Manual, Chapter 15, Section 220.2 D.):
“Skilled therapy services that do not meet the criteria for rehabilitation therapy may be covered in certain circumstances as maintenance therapy as a maintenance program. The goal of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances:
- Establishment or design of maintenance programs. …
- Delivery of maintenance programs. …
The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist, or whether they can be safely and effectively carried out by nonskilled personnel or caregivers.”
See also, American Physical Therapy Association (APTA), https://www.apta.org/Podcasts/Jimmo; CMS Information re Jimmo, https://www.cms.gov/medicare/settlements/jimmo; Center for Medicare Advocacy Jimmo Information, https://www.MedicareAdvocacy.org/medicare-info/improvement-standard/
In Summary: Outpatient Therapy to maintain function is coverable by Medicare. An expectation of improvement is not required.