Tuesday, September 22, 2015

Survey Results from the Jimmo Implementation Council

Earlier this summer, AHCA/NCAL was invited to participate in the inaugural Jimmo Implementation Council meeting on Capitol Hill with a select, multi-disciplinary group of professionals and health care leaders to discuss how well the Centers for Medicare and Medicaid Services (CMS) has done in implementing the provisions of the January 2013 Jimmo v. Sebelius settlement agreement.
As a refresher, in the lawsuit, the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled nursing facility, home health, and outpatient therapy benefits. In the settlement agreement, CMS agreed that an “Improvement Standard” is not to be applied in determining Medicare coverage for maintenance claims that require skilled care. Such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying necessity of the services themselves. The settlement agreement contained specific activities for CMS to implement, including issuing clarifications to existing program guidance and developing new educational material on this subject.
The day-long Jimmo Implementation Council meeting was convened by the Center for Medicare Advocacy, with the support of the John A. Hartford Foundation, identified several areas where attendees believed the CMS implementation may not have achieved the objectives outlined in the settlement agreement. Following the meeting, a survey of participants was conducted, and highlights of the results released by the meeting hosts this week are posted below:
Responses about Jimmo education to date offered mixed results:
  • 46% of respondents were not aware of the Jimmo Education Campaign provided by CMS in 2013.
  • Only 37% of respondents participated in the education efforts.
  •  However, 80% of respondents were aware of the Jimmo Fact Sheet released by CMS, and
  • 65% were aware that the Medicare Benefit Policy Manuals had been updated. 
  •  Also interestingly, of the small percentage of respondents who use Electronic Health Record Systems, just over half use a system that allows for documentation of care to maintain a patient’s condition. 
Clearly awareness and application of the Jimmo Settlement is currently far from universal. There is more work to be done.
There is widespread agreement among respondents that further well-funded research will be key to efforts to implement the Jimmo settlement. Suggestions included pilot studies of maintenance care patients v. non-maintenance patients with similar code-demographics; and use of home health records, as home health has had the ability to identify maintenance therapy since 2011. In addition, there is widespread concern about the understanding and application of Jimmo by Medicare Administrative Contractors. Many respondents also expressed concerns about the lack of clarity of guidelines for providers trying to document skilled maintenance care.
Future goals focused on by respondents included:
  • Going back to the Jimmo judge for reinforcement of the education component;
  • Working to get a National Coverage Determination that solidifies the Jimmo Settlement;
  • Ensuring proper Education of Medicare Administrative Contractor and other coverage decision-makers;
  • Seeking inclusion of clear provisions regarding Jimmo compliance in the Medicare Advantage Plan Call Letter;
  • Obtaining studies regarding the value of maintenance care for patients and the long-term costs, compared to those who go without;
  • Compiling a guide for beneficiaries and practitioners to understand, insist on and follow the Jimmo settlement;
  • Providing outreach to professional associations;
  • Obtaining guidance regarding acceptable documentation, especially from CMS, that would demonstrate medical necessity for maintenance therapy services;
  • Collecting stories, stories, stories!
AHCA/NCAL continues to identify and respond to member issues related to maintenance nursing and therapy services under Medicare Part A, Part B and Medicare Advantage. We encourage members to inform Dan Ciolek at dciolek@ahca.org or Mike Cheek at mcheek@ahca.org of any questions or comments you may have related to the survey results presented above, or if you are having any maintenance care coverage issues that are not being resolved through traditional channels.     

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