In January 2013, the Centers of Medicare
and Medicaid Services (CMS) entered into a settlement
agreement that was intended to assure Medicare coverage rights for
beneficiaries that may require skilled nursing or therapy services, but were
not expected to improve. The settlement agreement directed CMS to update
various policy manuals and provide educational outreach to assure that
providers and auditors understood that as long as the professional skills of
the therapist or nurse are required, services cannot be denied solely on the
lack of improvement in health or function, and that treatment goals of
maintenance, or the prevention or delay if decline can be appropriate.
A
recent court
decision, supported by an AHCA legal
declaration, found CMS non-compliant with the educational campaign
component of the settlement agreement. On February 16, 2017, the court ordered
CMS to improve their education efforts with specific activities, and to
issue a revised maintenance coverage corrective statement (see below) by
September 4, 2017.
In response, on August 23, 2017, CMS
published a webpage
to provide in one location, access to various public documents related to the Jimmo Settlement
Agreement. This webpage provides information and links to the background
of the settlement agreement, links to policy and educational resources, and a
newly developed Frequently Asked Questions (FAQ)
document.
This coverage policy clarification applies
to Medicare Part A, Part B, and Medicare Advantage in an office,
facility, or in the beneficiary’s home (including assisted living
center). Skilled nursing facility (SNF) nurses, therapists, and billers are encouraged to review
this new website.
Court Ordered Revised Maintenance Coverage
Corrective Statement:
The Centers for Medicare & Medicaid Services
(CMS) reminds the Medicare community of the Jimmo Settlement Agreement (January
2013), which clarified that the Medicare program covers skilled nursing care
and skilled therapy services under Medicare’s skilled nursing facility, home
health, and outpatient therapy benefits 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 Agreement required manual revisions to restate a “maintenance
coverage standard” for both skilled nursing and therapy services under these
benefits:
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.
The Jimmo Settlement Agreement may reflect
a change in practice for those providers, adjudicators, and contractors who may
have erroneously believed that the Medicare program covers nursing and therapy
services under these benefits only when a beneficiary is expected to
improve. The Jimmo Settlement Agreement is consistent with the Medicare
program’s regulations governing maintenance nursing and therapy in skilled
nursing facilities, home health services, and outpatient therapy (physical,
occupational, and speech) and nursing and therapy in inpatient rehabilitation
hospitals for beneficiaries who need the level of care that such hospitals
provide.
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