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  • CMS Publishes More Clarification on Jimmo Settlement and 'Improvement Standard' Myth

    The US Centers for Medicare and Medicaid Services (CMS) is making it clearer than ever that the so-called "improvement standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy. The new clarity on the validity of skilled maintenance is part of the agency's efforts to comply with a federal court finding that CMS had made "virtually no efforts" to educate stakeholders on the 2013 Jimmo v Sebelius settlement.

    CMS now offers a webpage exclusively devoted to the Jimmo settlement, which established that the improvement standard was a myth (for its part, CMS maintains that it never explicitly supported that standard, even though it was commonly used by contractors as a reason to deny payment). The agency's low-key efforts to educate contractors in the wake of the Jimmo settlement prompted Medicare beneficiary advocates to go back to the courts to compel CMS to do more, arguing that the improvement standard still was being applied by many contractors. APTA was a supporter of those efforts.

    In February, a federal court agreed with the patient advocates and ordered CMS to take "corrective action" that included publishing a new webpage on Jimmo that would contain, among other elements, a clear disavowal of the improvement standard and a list of frequently asked questions about the settlement. The judge gave CMS until September 4 to make it happen.

    CMS complied. Its new webpage states that skilled therapy services are covered by Medicare when an assessment reveals that "the specialized judgment, knowledge, and skills of a qualified therapist … are necessary for the performance of a safe and effective maintenance program " intended to "maintain the patient's current condition or to prevent or slow further deterioration."

    "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," CMS states on the webpage. "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."

    APTA offers a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.


    • Stroke patients

      Posted by Theresa Ellison on 8/26/2017 4:39 PM

    • Questions? Contact us at Center for Medicare Advocacy: Improvement@MedicareAdvocacy.org

      Posted by Judith Stein on 8/28/2017 11:06 PM

    • I don't see any clarification for those just non adherent to their home program....I see challenges ahead from those who want a personal trainer vs the instruction needed to maintain their own HEP....

      Posted by Colleen C on 8/31/2017 1:50 AM

    • The policy makers who wrongly interpreted by contracted intermediaries have committed crimes against medicare patients, denying them medical care and against those PT clinics who paid back money or closed their doors unable to pay. Not to mention the stress and anguish experienced by good intending PTs who found themselves up against the Federal government for providing legally covered care and were wrongfully persocuted financially. Class legal action should be inniciated to make whole thise patients and providers who were harmed.

      Posted by Wm scott barnett on 8/31/2017 8:45 AM

    • This information is of vital importance to all physical and occupational therapists. APTA would do a great service to open up its information pages on maintenance therapy to all therapists, not restrict it to the 30% who are members. Perhaps services to the therapy community such as this would draw new members who would support these educational efforts.

      Posted by Robert Weiss on 9/3/2017 4:56 PM

    • Is it accurate to say that a PTA can not treat a patient under maintenance therapy and it had to be done by a PT.

      Posted by Nina on 4/16/2018 11:53 PM

    • How is MIPS going to be consistent with Jimmo v. Sebelius?

      Posted by Brian on 11/16/2018 1:39 PM

    • I have been "fighting"to get this applied to my husband who is in a facility that still is using the old standard. It is frustrating when the administrator claims to be familiar with the JIMMO settlement and still withholds the services.

      Posted by Janet YENOR on 4/15/2019 10:24 AM

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