A U.S. District Court Judge in Vermont filed a decision
on February 1 ordering the Centers for Medicare and Medicaid Services (CMS) to
implement a Corrective Action Plan to improve education related to the coverage
of skilled therapy and nursing services needed to maintain health and function,
or “Maintenance Coverage”. This decision
impacts beneficiaries covered by Medicare Parts A & B, as well as and Medicare
Advantage, including those residing in nursing facilities and assisted living
centers.
This decision follows from an August 17, 2016 decision
in Jimmo v. Burwell that ruled that
CMS did not comply with part of the January 21, 2013 Jimmo v. Sebelius Settlement
Agreement. The initial settlement
included an agreement that added a “Maintenance Coverage” standard, and CMS
agreed to update their benefit policy and coverage manuals, engage in a
nationwide educational campaign, and be subject to other monitoring activities
to address disputes for three years. On
March 1, 2016, the plaintiffs filed a motion to enforce the Settlement
Agreement arguing that the CMS educational campaign “was so confusing and inadequate that little had changed,” and that
beneficiaries with chronic and progressive conditions under Medicare Part A,
Part B and Medicare Advantage, were being denied access to and coverage for
skilled therapy and nursing services to prevent or delay decline.
In support of the plaintiffs, AHCA/NCAL submitted a legal declaration
supporting the contention that the CMS education effort has not been “…adequate, timely, or complete.”
In the current decision,
the judge ruled that the CMS Corrective Action Plan, which must be certified as
compliant by September 4, 2017, include the following requirements:
1.
CMS publish a new web page dedicated to the Jimmo Settlement Agreement;
2.
CMS publish a Corrective Statement disavowing an
“Improvement Standard”;
3.
CMS post Frequently Asked Questions (FAQs);
4.
CMS develop and implement training for Medicare
Contractors and Medicare Advantage plans making coverage decisions, and;
5.
CMS conduct a new National Call to explain the
correct “Maintenance Coverage” policy.
Additionally, since the plaintiff’s and CMS could not agree on the language to be included in the “Corrective Statement” language to be published, the judge ordered the following statement, based mostly on suggested plaintiff language, to be published.
The Centers for Medicare &
Medicaid Services reminds the Medicare community of the Jimmo Settlement Agreement (January 2014), which clarified that
the Medicare program will pay for skilled nursing care and skilled
rehabilitation services when a beneficiary needs skilled care in order to
maintain function or to prevent or slow decline or deterioration (provided all
other coverage criteria are met). Specifically, the Jimmo Settlement adopted a "maintenance coverage
standard" for both skilled nursing and therapy services:
“Skilled nursing services would
be covered where such skilled nursing services are necessary to maintain the
patient's current condition or prevent or slow further deterioration so long as
the beneficiary requires skilled care for the services to be safely and
effectively provided.
“Skilled therapy services are
covered when an individualized assessment of the patient's clinical condition
demonstrates that the specialized judgment, knowledge, and skills of a qualified
therapist ("skilled care") are necessary for the performance of a
safe and effective maintenance program. Such a maintenance program to maintain
the patient's current condition or to prevent or slow further deterioration is covered
so long as the beneficiary requires skilled care for the safe and effective
performance of the program.
No comments:
Post a Comment