What is the Jimmo Settlement Agreement (January 2013)?
The Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits in order to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other coverage criteria are met), the Medicare program covers such services and coverage cannot be denied based on the absence of potential for improvement or restoration. In short, what the Settlement Agreement and the resulting revised manual provisions clarify is that Medicare coverage for skilled nursing and therapy services in these settings does not “turn on” the presence or absence of a beneficiary’s potential for improvement, i.e., it does not matter whether such care is expected to improve or maintain the patient’s clinical condition. In addition, although such maintenance coverage standards do not apply to services furnished in an Inpatient Rehabilitation Facility (IRF) or a comprehensive outpatient rehabilitation facility (CORF), the Jimmo Settlement Agreement clarified that for services performed in the IRF setting, coverage should never be denied because a patient cannot be expected to achieve complete independence in the domain of self-care or because a patient cannot be expected to return to his or her prior level of functioning. The Jimmo Settlement Agreement provided that these clarifications be included in the Medicare Benefit Policy Manual.
What is the effect of the Jimmo Settlement Agreement on other requirements for receiving Medicare coverage
The Jimmo Settlement Agreement included language specifying that nothing in the settlement agreement modified, contracted, or expanded the existing eligibility requirements for receiving Medicare coverage. While the Jimmo Settlement Agreement resulted in clarifications of the coverage criteria for skilled nursing and therapy services in the SNF, HH, OPT, and IRF care settings, it did not affect other existing aspects of Medicare coverage and eligibility for these settings. A few examples of such other requirements would include that the services be reasonable and necessary, comply with therapy caps in the OPT setting, and not exceed the 100-day limit for Part A SNF benefits during a benefit period.
How is coverage of skilled nursing and skilled therapy services under the SNF, HH, and OPT benefits to be determined?
Coverage of skilled nursing and skilled therapy services under these benefits does not turn on the presence or absence of a beneficiary’s potential for improvement or restoration, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition. Claims for skilled care coverage must include sufficient documentation to substantiate that skilled care is required, that it was in fact provided, and that the services themselves are reasonable and necessary, thereby facilitating accurate and appropriate claims adjudication.
If you have more questions about the Jimmo Settlement Agreement and its impact on your or a loved one’s situation, please call Takacs McGinnis Elder Care Law at 615.824.2571.
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