Medicare Coverage: Beneficiaries do not have to improve to qualify for Medicare Coverage

It is important to be aware of your rights under government provided programs. Based on the case, Jimmo v. Sebelius, beneficiaries no longer have to improve to qualify for Medicare coverage.

As a result of the Jimmo Settlement, the Centers for Medicare & Medicaid Services (CMS) was required to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not on a beneficiary’s potential for improvement. Coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” (CMS Transmittal 179, Pub 100-02, 1/14/2014).

The Jimmo Settlement means that Medicare beneficiaries should not be denied coverage for maintenance nursing or therapy provided by a skilled nursing facility, home health agency, or outpatient therapy provider when skilled personnel must provide or supervise the care for it to be safe and effective. Medicare-covered skilled services include care that improves, maintains, or slows the decline of a patient’s condition. Medicare coverage is not allowed to be denied solely because an individual has an underlying condition that won’t get better, such as MS, ALS, Parkinson’s disease, or paralysis.

Source: https://www.medicareadvocacy.org/wp-content/uploads/2018/12/Jimmo-Fact-Sheet-for-Providers-Contractors-Adjudicators.pdf