Medicare Program Manual Updated Based on Jimmo Decision

Earlier this year, the decision in Jimmo vs. Sebelius required that the Centers for Medicare & Medicaid Services (CMS) provide clarification and education regarding determinations for Medicare coverage of skilled care, home health care and outpatient therapy. Prior to Jimmo, plaintiffs claimed that Medicare contractors were applying an “Improvement Standard” to determining whether these services would be covered or not. Specifically, beneficiaries that did not seem to have “restoration potential” had their coverage claims denied, even though skilled care was required. CMS noted that it has long recognized that there are situations where a beneficiary may not be expected to improve and that skilled care may be required to prevent or slow deterioration or maintain a maximum practicable level of functioning.

In its Jimmo v. Sebelius Settlement Agreement Fact Sheet, CMS states that a “beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage, without regard to an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care or services in question.” It further states that if care needs can be met safely and effectively through the use of nonskilled care, then coverage for skilled care would not be available. As part of the updates to the Medicare Policy Manual revisions that CMS made on December 9, 2013, the Program Manual Clarifications Fact Sheet provides additional information regarding the documentation that should be provided to establish the need for skilled services.

The updated CMS Medicare Program Manual not only provides guidance on the type of documentation that is considered appropriate for coverage claims, but also clarifies that there is no “Improvement Standard” that can be applied to determining coverage. The effective date for these changes is January 7, 2014.

In addition to providing updates to the Medicare Manual, as part of the settlement, CMS is also required to provide education regarding the clarifications it has made. On December 19, 2013, there is a MLN Connects National Provider Call, “Program Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. Sebelius.”

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