Improvement not required

March 6, 2019

Contrary to what some skilled care facilities say, a patient need not be improving in order to continue to receive Medicare coverage for skilled care after a hospitalization. 

 

The actual standard is whether skilled care and therapy is "necessary to maintain the patient’s current condition or prevent or slow further deterioration." The NYT article here gives more background on the confusion and the settlement agreement reached in 2013 which should have put this issue to rest.

 

This information is important for individuals who have a relative receiving skilled care post hospitalization. 

 

The Settlement Agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. Vt) was approved by a federal district court in January 2013. Even though it has been more than six years since the Settlement’s approval, the Center for Medicare Advocacy still regularly hears from beneficiaries facing erroneous “Improvement Standard” denials in home health, skilled nursing facility, and outpatient therapy settings. As a result, the Center advises beneficiaries and their families to continue citing the Jimmo Settlement and related materials when challenging denials based on an erroneous “Improvement Standard.”

 

Source/more: Center for Medicare Advocacy

See also: CMS Statement about Jimmo

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