Medicare coverage of skilled nursing and/or therapy services depends on a beneficiary’s need for the skilled care, not on the individual’s potential for improvement. The Settlement Agreement in Jimmo v. Sebelius, approved by a federal district court in 2013, required the Centers for Medicare & Medicaid Services (CMS) to confirm that coverage of skilled nursing or therapy is available to maintain or slow the decline of an individual’s condition. The Settlement also confirmed that coverage of inpatient rehabilitation hospital/facility care does not depend on a beneficiary’s ability to achieve complete independence in self-care or a prior level of functioning. The Jimmo Settlement pertains to all Medicare beneficiaries in home health, skilled nursing facilities, outpatient therapy, and inpatient rehabilitation hospitals/facilities throughout the country.
Unfortunately, more than six years after the Settlement’s approval, the Center still regularly hears from Medicare beneficiaries and providers about problems with its implementation. In the face of enduring barriers to Medicare-covered care, and with support from the John A. Hartford Foundation, the Center has developed self-help resources to assist beneficiaries and families push back against inappropriate denials of care based on an erroneous “Improvement Standard.”
Latest Resources from the Center for Medicare Advocacy
Skilled Nursing Facilities
- Medicare Outpatient Therapy Coverage and Appeals In Light of Jimmo v. Sebelius
- Congress Repeals Medicare Outpatient Therapy Caps, Strengthening the Jimmo Settlement Agreement
Inpatient Rehabilitation Hospitals/Facilities
- Jimmo v. Sebelius Update – Medicare Coverage for Maintenance Care, CMS Corrective Action Plan and Implementation