Learn when and why Skilled nursing services would be 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.
The Jimmo Settlement often reflects a change in practice for providers, adjudicators, and contractors who may erroneously believe that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve. The Centers for Medicare & Medicaid Services (CMS) must educate the Medicare community regarding the Jimmo Settlement Agreement (January 2014). The Settlement clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met). The Jimmo Settlement was followed by CMS Manual revisions to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits
Equally as important to understand are when Skilled therapy services are covered following 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.
Managers, clinical therapy and nursing staff who are unaware of this mandate could risk improper delivery of care per CMS guidelines. The Settlement is consistent with the Medicare program’s regulations governing maintenance nursing and therapy in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and nursing and therapy in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide.
Description of the topic
The Jimmo v. Sebelius case challenged Medicare’s use of an “Improvement Standard” to make coverage determinations. The result was a lawsuit brought on behalf of Six individuals representing a Nationwide class of Medicare beneficiaries as well as National organizations representing people with chronic conditions. The settlement addresses Medicare terminating or denying coverage to beneficiaries who are not improving for Medicare Part A and Part B benefits. The Settlement was approved on January 24, 2013, yet there is a huge percentage of clinicians and managers who are unable to advocate for services mandated through the settlement. In February 2017, the court issued a corrective statement that is to be incorporated in the CMS Corrective Action Plan.
With the publication of the CMS Corrective Statement, the government intends to make it extremely clear that Medicare coverage can be available for skilled therapy and nursing that is needed to maintain an individual’s condition or slow deterioration. The goal is to advance access to Medicare and necessary care for people with long-term and debilitating conditions.
Is your team aware of the CMS published Corrective Statement? Obtain answers to Jimmo. Frequently Asked Questions and Jimmo resources. How to identify candidates who qualify under this Settlement as well as goal setting and treatment planning approaches will be discussed.
Areas Covered In The Session
• Review key points of the Jimmo v. Sebelius
• CMS Response
• CMS Policies related to Maintenance programming
• Implications of the corrective statement
• CMS Manual updates
• Practical Application for Medicare Part A and B
• Clinical Considerations for nursing and therapy
• Attendees will be able to state the court mandated corrective statement for the Jimmo Settlement
• Attendees will be able to identify patients/candidates who qualify for skilled therapy and nursing under
the Jimmo Settlement
• Attendees will be able to state 2 goals consistent with treatment planning under the Jimmo Settlement
• Leaders will be able to identify a plan for education and training of the Jimmo Settlement within their
Who Should Attend
• Nurse Managers
• Utilization Review/Quality Improvement Staff
• Rehabilitation Directors
• Utilization Review/Quality Improvement Staff
• Health Information Management Staff
• Therapy professionals
MEET THE PRESENTER
Elisa Bovee has been working in the healthcare environment advocating for patients through education and clinical guidance for over 20 years. With a Masters degree in Occupational Therapy she has managed a national operations team performing audits and analysis across the US for skilled nursing and healthcare providers. Her expertise includes Compliance Programs, Regulatory guidelines, development of Education programs, Reimbursement and skilled documentation for nursing and therapy professionals. Managing claims through the Development Request and Denial phases is Ms. Bovee’s forte. Elisa presents programs nationally targeting all interdisciplinary groups seeking guidance and clarity on a multitude of Regulatory and clinical topics. Elisa has written and contributed to articles for numerous national trade publications.