The National Association of Insurance Commissioners (NAIC) is a standard-setting and regulatory support organization governed by chief insurance regulators from across the country. NAIC’s website indicates that organizational members and its resources, “form the national system of state-based insurance regulation in the U.S.” One such resource is NAIC’s Glossary of Health Insurance and Medical Terms, which defines ‘rehabilitation’ as follows:
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings (emphasis added).
NAIC’s definition recognizes that rehabilitation services may not only be necessary to improve a patient’s condition but may also be necessary to “keep” his or her skills and functioning. This definition confirms the Settlement Agreement in the nationwide class-action lawsuit Jimmo v. Sebelius, No. 5:11-CV17 (D. VT).
Approved by a federal district court in January 2013, the Jimmo Settlement required the Centers for Medicare & Medicaid Services (CMS) to confirm that Medicare coverage of skilled nursing and/or therapy services is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. As a result, Medicare policy now clearly states that coverage:
[D]oes not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.
Bolstering NAIC’s recognition of maintenance care, the Jimmo Settlement means that Medicare beneficiaries must not be denied coverage for maintenance nursing or therapy provided by a skilled nursing facility, home health agency, or outpatient therapy provider when skilled personnel must provide or supervise the care in order for it to be safe and effective. Medicare coverage should not be denied solely because an individual has an underlying condition that won’t get better, such as MS, ALS, Parkinson’s disease, or paralysis.
If Medicare coverage is denied based on an erroneous “Improvement Standard,” please visit the Center’s Improvement Standard and Jimmo News webpage for our setting-specific self-help materials. Although challenging a Medicare denial may seem daunting, beneficiaries and their representatives can win appeals when equipped with the right information.
June 13, 2019 – D. Valanejad
 CMS Transmittal 179, Pub 100-02, 1/14/2014; See also Medicare Benefit Policy Manual (MBPM), Chapter 7 – Home Health Services, Section 20.1.2, 40.1-.2; MBPM, Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance, Sections 30.2-.4; MBPM, Chapter 15 – Covered Medical and Other Health Services, Sections 220, 220.2-.3, 230.1.2.