Many people receiving physical or occupational therapy after a stroke, injury or chronic illness have been told that Medicare would no longer pay for such therapies if the patient “plateaus” or stops making improvement. This was known as the “improvement standard” for continued Medicare coverage of such therapeutic treatments.
However, this improvement standard has never been part of the law of Medicare, and in 2013 the federal Medicare agency entered into a litigation settlement acknowledging that there is no requirement that a patient continue to improve in order to receive Medicare payments for therapies. It is sufficient for Medicare coverage if the services are necessary to maintain function and avoid decline (a “maintenance standard”). We reported on this Jimmo v. Sebelius court settlement in an earlier blog post.
Since the Jimmo case, many providers of therapeutic services have been unaware or confused about the process for continuing Medicare coverage of therapies for patients who require them to function or avoid decline. On February 13, 2024, the Centers for Medicare & Medicaid Services (CMS) issued several important reminders to providers and adjudicators in traditional Medicare and Medicare Advantage to refresh and train staff and contractors with links to its Jimmo Settlement page.
Among other things, CMS included the following language in all its February 2024 reminders: “Specifically, the Jimmo Settlement required manual revisions to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits:
- Skilled nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration, so long as the beneficiary requires skilled care for the services to be safely and effectively provided.
- Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.