The Centers for Medicare & Medicaid Services in August unveiled the educational webpage mandated as part of the federal government’s January 2013 Jimmo settlement.
The ruling clarified Medicare’s longstanding policy that coverage of skilled nursing and therapy services in the skilled nursing facility, among other settings, does not depend on an “improvement standard,” but rather on the individual’s need for skilled care.
The settlement agreement directed CMS to update various policy manuals and provide more educational outreach to assure that providers and auditors understood the stipulations of the landmark ruling. As long as the skills of the therapist or nurse are required, services cannot be denied solely on the lack of improvement in health or function; treatment goals of maintenance, or the prevention or delay of decline, can be appropriate.
In 2016, a U.S. District Court ruled that CMS hadn’t done enough to explain maintenance coverage to everyone.
The new webpage includes a revised maintenance coverage corrective statement and links to background materials on the settlement agreement. It also has a list of frequently asked questions on the Jimmo settlement, as well as additional resources on Medicare’s skilled nursing benefit and manual updates.
“The Jimmo Settlement Agreement does not represent an expansion of coverage, but rather, it provides clarifications that are intended to help ensure that claims are adjudicated accurately and appropriately in accordance with the existing Medicare policy,” CMS says on the website. “Similarly, the Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary.”