CMS Launches Court-Ordered Jimmo Settlement Agreement Webpage

Dan Ciolek

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.