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Skilled care does not require improvement
A common myth is that Medicare stops paying once a patient stops improving. CMS has said clearly that this is not the rule.
The short answer
Medicare covers skilled nursing and therapy needed to maintain a patient's condition or prevent or slow decline, as long as skilled care is required and all other coverage rules are met. Improvement is not a requirement.
What the settlement says
The January 2013 Jimmo settlement clarified that coverage for skilled nursing and skilled therapy does not depend on whether a patient is expected to improve. It depends on whether the patient needs skilled care (CMS Jimmo Settlement). The settlement applies to home health, skilled nursing facility and outpatient therapy benefits.
Maintenance nursing and therapy
Skilled nursing can be covered when it is needed to maintain the patient's condition or prevent or slow decline and skilled care is required to provide it safely. Skilled therapy can be covered when a therapist's judgment and skills are needed to set up or deliver a safe and effective maintenance program.
What did not change
Services must still be reasonable and necessary, and the patient must still meet the home health rules, including homebound status and a physician's order. The settlement does not create unlimited coverage. It removes improvement as a test.
Why it matters for families
Patients with Parkinson's disease, multiple sclerosis, heart failure or other long-term conditions may benefit from skilled care that keeps them stable at home. If you are told care must end only because the patient is not improving, ask the agency and the physician to review the skilled need, and ask about your appeal rights.
Questions
Quick answers
Does Jimmo mean Medicare covers care forever?
No. Each patient must continue to need skilled care and meet all other coverage rules.
Sources
General information only. This article is not medical, legal or coverage advice. Talk with your physician about your care. In an emergency, call 911. Please do not send patient health information through this website.
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