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Understanding Medicare Coverage for Maintenance Claims

Thanks to a long-awaited revision in the Medicare Policy Manuals, it may be a little easier to receive Medicare coverage for maintenance claims that require skilled care.

In late 2013 and early 2014, the Centers for Medicare & Medicaid Services revised its Medicare Policy Manuals pursuant to Jimmo v. Sebelius. The revisions clarify that “No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims which skilled care is required.”

On January 24, 2013, an order finalizing a settlement agreement to the “Improvement Standard” case, Jimmo v. Sebelius, was signed. After the settlement agreement was finalized the Centers for Medicare & Medicaid Services was tasked with revising its Medicare Benefit Policy Manual and a number of other policies, guidelines and instructions to ensure that Medicare coverage is available for skilled maintenance services in the home health, nursing home and outpatient settings, and to correct suggestions that Medicare is dependent on the improvement of a beneficiary.  

Pursuant to Jimmo, medically necessary therapy and nursing services, provided by or under the supervision of skilled personnel, may be covered by Medicare if the services are necessary to maintain the individual’s condition, or prevent or delay the individual’s decline.

The settlement clarified what should have always been the Medicare coverage standard. The Settlement was retroactive to the date the case was filed, January 18, 2011, and established a “re-review” process for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services from that date.

The revisions pertain to care in Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health care (HH), and Outpatient Therapies (OPT). In addition, 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.

For a wonderful resource, if you have questions regarding your Medicare Coverage, go to the Center for Medicare Advocacy at

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