NAPGCM Public Policy E-Newsletter: Improvement Standard Update: CMS Revises Medicare Policy January 28, 2014

Improvement Standard Update: CMS Revises Medicare Policy
Released to NAPGCM Membership on January 28, 2014

The Centers for Medicare and Medicaid Services (CMS) recently revised their Medicare Policy Manuals, pursuant to the Jimmo v. Sebelius Settlement, to clarify that improvement is not required to obtain Medicare coverage for skilled nursing facility (SNF), home health, or outpatient physical therapy services.

The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted on the CMS website here.

A CMS MLN Matters article is also available on the CMS site here.

CMS states in the Transmittal announcing the Jimmo Manual revisions:

No "Improvement Standard" is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an "Improvement Standard" rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient's condition. Thus, such coverage depends not on the beneficiary's restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.

Per the Jimmo Settlement, CMS will now implement an Education Campaign to ensure that Medicare determinations for SNF, Home Health, and Outpatient Therapy turn on the need for skilled care - not on the ability of an individual to improve. For inpatient rehabilitation facilities patients, the Manual revisions and CMS Education Campaign clarify that coverage should never be denied because a patient cannot be expected to achieve complete independence in self-care or to return to his/her prior level of functioning.

Geriatric care managers may want to challenge a provider of rehabilitation services based on this new directive. The Center for Medicare Advocacy, who helped to represent the plaintiffs in the Jimmo vs. Sebelius lawsuit, is offering to assist with resources as well as information about questioning benefits. If GCMs have questions about this situation, click here for more information.