Jimmo Agreement: Medicare Coverage for Skilled Care

June 10, 2014
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In previous blog articles we spoke about the Jimmo v. Sebelius settlement (December,2013 / March, 2013 / December, 2012). After the settlement was finalized March, 2013, we wrote:

The Jimmo agreement settles once and for all that Medicare coverage is available for skilled services to maintain an individual’s condition. Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will “improve.” According to the Center for Medicare Advocacy, for decades, Medicare beneficiaries particularly those with long-term or debilitating conditions and those who need rehabilitation services have been denied necessary care based on the “Improvement Standard”. This illegal practice has resulted in Medicare coverage for vital care being denied to thousands of individuals on the grounds that their condition was stable, chronic, not improving, or that the necessary services were for “maintenance only.” The use of this illegal standard has had a particularly devastating effect on patients with chronic conditions such as Multiple Sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease and paralysis. Now, Medicare can be available for therapy that is needed to maintain the person’s condition or to prevent further deterioration. It is not always necessary for the individual’s underlying condition to improve to continue to qualify for Medicare coverage!

However, despite the installation of the Jimmo agreement, it appears that many Medicare beneficiaries are unaware of the changes and what exactly they are entitled to. This may be due to a lack of education provided to both consumers and providers about the changes. Because of this we would like to take this opportunity to remind our readers of the following, as stated by the Centers for Medicare and Medicaid Services in a January, 2014 publication:

“Accordingly, these revisions to the MBPM clarify that a beneficiary’s lack of restoration potential cannot serve as the basis for denying coverage in this context. Rather, such coverage depends upon an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Moreover, when the individualized assessment demonstrates that skilled care is, in fact, needed in order to safely and effectively maintain the beneficiary at his or her maximum practicable level of function, such care is covered (assuming all other applicable requirements are met).”

If you or a loved one is insured by Medicare and is currently paying out-of-pocket for health care services necessary to maintain the health condition, it is advised that you seek further information regarding the potential coverage of these services by Medicare.

The Center for Medicare Advocacy also provides more information on this topic at the following: http://www.medicareadvocacy.org/medicare-info/improvement-standard/#.UpykK53CFmI.email

Be sure to also read our blogs on Observation Status in the hospital as they directly relate to Medicare coverage in SNF’s.

Please contact our office if you have any questions at (631) 424-2800.

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