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From Health Law Daily, August 24, 2017

New website provides links to Jimmo settlement documents

By Susan L. Smith, JD, MA

CMS announced a new webpage to provide background, links to resources, and answers to frequently asked questions related to the Jimmo Settlement Agreement, which was approved by the District Court of Vermont in January 2013. According to CMS, the settlement agreement required CMS to clarify Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in skilled nursing facility, home health, and outpatient therapy benefits "does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care." CMS noted that the settlement follows the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, outpatient therapy, and nursing and therapy in inpatient rehabilitation hospitals.

Maintenance coverage standard. The webpage explains that the settlement agreement required CMS to revise its manuals, including the Medicare Benefit Policy Manual (Pub. 100-02, Chapter 1, secs. 110.2 and 110.3, and Chapter 7, secs. 20.1.2, 30.1.2, 40.1, and 40.2) to provide a "maintenance coverage standard" for both skilled nursing and therapy services. Under the revised maintenance coverage standard, skilled nursing services are covered when they are necessary to maintain the patient's current condition or prevent or slow further deterioration if 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 are necessary for performing a safe and effective maintenance program. Such a maintenance program to maintain the patient's condition or to prevent or slow further deterioration is covered if the beneficiary requires skilled care for the safe and effective performance of the program.

No denial absent improvement. CMS emphasized that coverage cannot be denied based on the absence of potential for improvement or restoration and pointed out that for providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services only when a beneficiary is expected to improve, the Jimmo Settlement Agreement may reflect a change in practice.

See Frequently Asked Questions for further details regarding the Jimmo Settlement Agreement.

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