In January 2013, an agreement was approved in the case of Jimmo v. Sebelius. The plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage of skilled nursing facility, home health, and outpatient therapy benefits.
In your work as SHINE counselors, you may have assisted beneficiaries who have been denied coverage for skilled nursing care, home health care, or outpatient therapy because they are not improving or have “plateaued”. Or providers may have told them Medicare is likely to deny their future claims for the same reason and so the beneficiary has stopped services.
CMS is affirming that claims for skilled nursing care, home health, and outpatient therapy (physical, occupational, and speech) should not be denied on the basis of this “Improvement Standard”. Instead, coverage should be provided when “skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration”. In other words, Medicare will cover skilled services that maintain a person’s condition or prevent it from worsening.