On February 8, the Centers for Medicare and Medicaid Services (CMS) posted a reminder in the
MLN Connects newsletter that Medicare covers skilled nursing care and skilled therapy services under skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care
to maintain function or
to prevent or slow decline, as long as:
- The beneficiary requires skilled care for the services to be provided safely and effectively
- An individualized assessment of the patient's condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are needed for a safe and effective maintenance program
Providers are encouraged to visit the
CMS Jimmo Settlement Agreement webpage for more information. This webpage was established as part of a 2013 Jimmo v. Sebelius class action lawsuit settlement agreement on behalf of beneficiaries throughout the country who were denied Medicare coverage for skilled care because they were not improving. The settlement confirmed that access to Medicare coverage should be determined based on the beneficiary’s need for skilled care, not potential for improvement. However, advocacy groups note that some providers and claim auditors continue to apply a non-existent improvement standard. This notice is an attempt to address this ongoing issue.
Additionally, and concurrent to this announcement, per the
Center for Medicare Advocacy, CMS also issued similar reminders to claim auditors in traditional Medicare and Medicare Advantage to refresh and train staff and contractors as follows:
- A Technical Direction Letter (TDL) released on 1/25/24, directing the Part A and Part B Qualified Independent Contractors (QICs), and the Part C Independent Review Entity (IRE) to conduct staff training on the coverage and payment policies related to skilled therapy pursuant to the Jimmo Settlement Agreement, and providing links to materials for use in conducting the training.
- A separate TDL issued on 2/7/24 directing the Medicare Administrative Contractors (MACs) to conduct staff training on the coverage and payment policies related to skilled therapy pursuant to the Jimmo Settlement Agreement, including links to materials for use in conducting staff training and provider education.
- A Health Plan Management System (HPMS) memo issued on 2/13/24 directing Medicare Advantage Organizations (MAOs) to conduct staff and contracted provider training on the coverage and payment policies related to skilled therapy pursuant to the Jimmo Settlement Agreement, including links to materials for use in conducting the training.
- In addition, CMS shared the direction provided to contractors with the Center for Program Integrity (CPI), the Office of Legislation (OL), the Office of Medicare Hearings and Appeals (OMHA), and the Office of Inspector General (OIG).