The Jimmo v. Sebelius lawsuit was brought on behalf of a nationwide class of Medicare beneficiaries by six individual Medicare beneficiaries and seven national organizations representing people with chronic conditions. The Jimmo v. Sebelius case challenged Medicare's use of an "Improvement Standard" to make coverage determinations. On January 24, 2013, a settlement was approved by the federal district court of Vermont expanding Medicare Part A and Part B coverage to include the rendering of skilled nursing and therapy services necessary to maintain a person's condition.
CMS must now revise the Medicare Benefit Policy Manual and all other Medicare Manuals to correct suggestions that Medicare coverage is dependent on a patient "improving." CMS is also required to initiate a comprehensive nationwide educational campaign to inform health care providers, Medicare contractors, and Medicare adjudicators that they should not limit Medicare coverage only to beneficiaries who have the potential for improvement. New policy provisions will state that skilled nursing and therapy services necessary to maintain a person's condition meet Medicare Part A an B coverage requirements.
The Jimmo settlement agreement reinforces the current Medicare coverage criteria for the establishment and implementation of a maintenance program for patients with chronic conditions and anticipated deterioration. The settlement agreement extends Medicare coverage criteria to include the actual delivery of medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline.
While providers wait for CMS to issue instructions to Medicare contractors, Harmony recommends providers review Medicare's current coverage requirements and documentation requirements related to the development and implementation of maintenance programs by Physical, Occupational and Speech therapies. The first step in this process is individualized assessment of the patient’s clinical condition that must clearly demonstrate that the specialized judgment, knowledge, and skills of a qualified therapist or nurse are necessary to develop and implement an effective maintenance program. The patient's medical complexity must support the medical necessity of skilled therapy and or nursing services. Skilled therapy services provided to patients with chronic medically complex conditions have been a focus for denial without the specific documentation to support that the skills of a therapist were required.
In preparation for CMS' instructions, providers should ensure that all patients have access to available Medicare Part A and B benefits when a patient would clinically benefit from the development and implementation of a maintenance program. Providers would then be poised to initiate the actual rendering of these skilled nursing and rehabilitation services to maintain function, prevent or slow functional decline when CMS provides more detailed explanation on coverage guidelines.
Do your medical records support skilled care?