Dec 102013

Earlier this year, in the wake of the widely reported end of the so-called “improvement standard,” we fielded a call from a distraught caregiver, whose providers challenged her when she insisted on additional services for her homebound spouse. He was not likely to improve, they said—and they were unaware of the class action settlement which had changed the rules. Patients need not be improving to be eligible for skilled nursing care.

Trying to spread the word about this major change in Medicare policy is a Herculean task, and our colleagues at the Center for Medicare Advocacy continue to do just that. Information below is pulled from information released via email today.

As required by the Jimmo vs. Sebelius Settlement, the Medicare Policy Manuals have now been revised. The Jimmo case ended a longstanding practice denying Medicare coverage to people who had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” The Manual revisions, which clarify that improvement is not required to obtain Medicare coverage, were published by the Centers for Medicare & Medicaid Services (CMS) on Friday December 6, 2013. The manuals pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health care (HH), and Outpatient Therapies (OPT).

In the Transmittal announcing the Jimmo Manual revisions, CMS writes:

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 and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly. [Emphasis in original.]

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care – not on the ability of an individual to improve. For IRF patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning.

“As with components of all settlement agreements, the Jimmo revisions are not perfect,” says Judith Stein, Executive Director of the Center for Medicare Advocacy. “But they do make it absolutely clear that skilled care is covered by Medicare for therapy and nursing to maintain a patient’s condition or slow decline – not just for improvement.”

Plaintiffs in Jimmo vs. Sebelius are represented by the Center for Medicare Advocacy and Vermont Legal Aid. Jimmo is a certified national class action lawsuit brought by individual Medicare beneficiaries and national organizations. It was formally settled by the Plaintiffs and Secretary Sebelius on January 24, 2013, when federal Judge Christina Reiss approved the settlement Agreement.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website. The CMS MLN Matters article is also available on the CMS site under “Downloads.

CMS Webinar on Clarification:

Medicare providers are encouraged to register and participate in an upcoming webinar hosted by CMS as a component of the educational campaign to review the changes to the policy manuals. Registration information available here:

If you’re not a Medicare provider, you can still help ensure the Improvement Standard is eliminated – tell your health care and therapy providers about the webinar and encourage them to sign-up!

Read here for more details on the Improvement Standard and the Jimmo case.

key words: Center for Medicare Advocacy, Jimmo, Improvement Standard, Medicare

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  One Response to “Update on End of Improvement Standard: New Medicare Policy Manuals Released”

  1. Serious reform to build a workable system for frail elderly people required this decision – acknowledging that skilled professional help is legitimate for maintaining function and slowing the rate of decline, just like for improving health. However, the decision does open the doors for substantial overuse of professional help, running up major costs with little gain. So, new standards on appropriate care and new metrics to guide service delivery are in order – and quickly!

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