The Centers for Medicare and Medicaid Services has revised the Medicare Benefit Policy to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve, per the settlement in the high-profile Jimmo vs. Sebelius case.
The filing of the lawsuit in Jimmo sought to end the industry-wide practice of denying Medicare coverage to patients who “plateaued” in their rehabilitation. Plateaued included “not likely to improve” “chronic” and “stable”. As part of the settlement, the Center for Medicare and Medicaid Services (CMS) agreed to educate and promote to all Medicare providers and consumers that improvement is not the standard to continue to receive Medicare payment for rehabilitation, home health care and outpatient treatments.
CMS stated in announcing the revision to its Medicare Policy Manual:
No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness of necessity of the services themselves. The manual revision now being issued will serve to reflect and articulate this basic principal more clearly.