Jimmo v. Sebelius Settlement Clarifying Scope of Skilled Coverage Takes Effect Today: Additional Guidance Available

Revisions of the Centers for Medicare and Medicaid Services (CMS) Medicare policy manual related to the Jimmo v. Sebelius “Improvement Standard” settlement take effect today, Jan. 7, 2014.  With the publication by the CMS of these revisions and official guidance, it is clear that this represents a significant and important clarification of the scope of Medicare skilled coverage. CMS summarizes these revisions in MLN Matters article 8458.  According to CMS:

"No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required. Medicare has long recognized that even in situations where no improvement is expected, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition)."

This concept applies to both skilled nursing and therapy services. For skilled nursing facility and home health agency providers, this may provide increased flexibility in providing residents/patients with Medicare Part B covered skilled care.

CMS held a teleconference on Thursday, Dec. 19 entitled, Program Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. Sebelius. The slides from this program are available by clicking here, and an encore recording should be posted soon. LeadingAge also posted information on the revisions, available by clicking here.

LeadingAge New York will be presenting a free member audio conference (charge to non-members) entitled, New Opportunities from the Jimmo v. Sebelius Settlement, scheduled for Jan. 22 from 10:30 to 11:30 a.m.  Although there is no charge for members, registration is required and available by clicking here.  There is likely to be a period of some confusion until providers, patients, Medicare Advantage plans and Medicare administrative contractors adjust to this clarification.  We hope that this audio conference will prove to be yet another resource to assist our members during this transition.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827