- Settlement in the Medicare Improvement Standard case, Jimmo v. Sebelius, was approved on January 24, 2013 by a federal judge during a scheduled fairness hearing.
- Case involved woman denied Medicare coverage for treatment of her chronic diabetes related conditions.
- As a result of the settlement with the Department of Health and Human Services, individuals who need maintenance care for conditions that are not improving CAN NO LONGER BE DENIED MEDICARE COVERAGE UNDER AN IMPROVEMENT STANDARD.
- CMS will need to update policy manual and undertake an educational campaign to increase awareness of the policy.
- Determining issue for Medicare coverage is whether the SKILLED SERVICES of a health care professional are needed NOT whether the beneficiary will improve.
- Skilled services covered when they are required to maintain a patient’s condition, or prevent further deterioration.
- Standards apply NOW.
- Applies to both Medicare Part A and Medicare Part B services.
- Applies to Medicare Advantage as well as traditional Medicare programs.
- Settlement not limited to particular conditions or diseases. Applies to anyone who requires skilled service to maintain or slow deterioration regardless of underlying illness, disability or injury.
- Applies in Medicare home health, outpatient therapy and skilled nursing facility settings.
- Settlement does not increase the coverage benefit period of 100 days in a SNF.
- Settlement is retroactive to January 18, 2011.
- A re-review process will be established by CMS for beneficiaries who received a denial for skilled services. Support will be provided by our therapy teams for clients and patients who will need to participate in the process to be established by CMS and the MACs.
- Indicate in the Plan of Treatment that the services being provided are skilled maintenance services.
- Indicate the diagnosis for which the skilled maintenance services are being provided and reason for current intervention.
- Be sure to justify skilled intervention in daily and weekly notes to support services.
- Be sure to tie the treatment provided in the maintenance program to functional activities that will maintain the patient’s quality of life.