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CMS Website About Jimmo Ruling is Now Posted

The Jimmo v. Sebelius case, settled in 2013, clarified Medicare coverage of nursing services and therapy to prevent deterioration, the so-called "maintenance coverage" standard.  The clarification was necessary to dispense with a long-held erroneous belief that Medicare only covered nursing and therapy services when the beneficiary was expected to improve.  Ironically, there had never been an improvement standard—it was an urban coverage myth of sorts.   This belief had been widely institutionalized among various Medicare contractors, who relied on it to deny claims for therapy when the potential for further improvement could not be documented. 

Although the case has been settled for several years, and the settlement agreement required CMS to make clarifying changes to the Program Manuals and to conduct an educational campaign, there continued to be claims' denials and widespread misunderstanding of the coverage rule.  The plaintiffs returned to court in 2016 (Jimmo v. Burwell) asking for additional educational effort.  A judge ruled in February 2017 that a corrective action plan to live up to the settlement terms had to include a webpage dedicated to Jimmo, a public statement disavowing the "improvement" standard, a posting of FAQs and training for contractors making coverage decisions.  Also, a national call was conducted to explain the proper coverage policy.  

The court-ordered Jimmo webpage contains a clarifying message from CMS as well as links to several related resources which includes the Jimmo Settlement Agreement along with a fact sheet, a Program Manual clarification and fact sheet, an MLN Matters Article covering manual updates to clarify SNF, HH, OPT Coverage after Jimmo; a record of the national coverage call and revised sections of the Benefit Policy Manual.  The webpage also includes FAQs and contact numbers for further information.


Julie A. Knutson

 

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