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On February 1st, a Vermont U.S. District Court Judge filed a decision ordering CMS to implement a Corrective Action Plan for improved education related to skilled therapy and nursing service coverage required to maintain health and function (aka “Maintenance Coverage”). This decision impacts beneficiaries covered by Medicare Part A, Part B and Medicare Advantage.

This update follows an earlier decision in Jimmo v. Burwell ruling that CMS did not comply with part of the Jimmo v. Sebelius Settlement Agreement which contained several requirements for CMS including a “Maintenance Coverage” standard, benefit policy & coverage manual updates, a nationwide educational campaign, and other monitoring activities to address disputes for three years. In March 2016, the plaintiffs filed a motion to enforce the Settlement Agreement stating that beneficiaries with chronic and progressive conditions continued to be denied coverage for skilled services needed to slow decline or maintain function, and that the CMS educational campaign “was so confusing and inadequate that little had changed.”

In this month’s decision, the judge ruled that the CMS Corrective Action Plan, which must be certified as compliant by September 4, 2017, include the following requirements:

CMS publish a new web page dedicated to the Jimmo Settlement Agreement
CMS publish a Corrective Statement disavowing an “Improvement Standard”
CMS post Frequently Asked Questions (FAQs)
CMS develop and implement training for Medicare Contractors and Medicare Advantage plans making coverage decisions
CMS conduct a new National Call to explain the correct “Maintenance Coverage” policy

Additionally, the judge ordered the following statement to be published:

“The Centers for Medicare & Medicaid Services reminds the Medicare community of the Jimmo Settlement Agreement (January 2014), which clarified that the Medicare program will pay for skilled nursing care and skilled rehabilitation services 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). Specifically, the Jimmo Settlement adopted a “maintenance coverage standard” for both skilled nursing and therapy services:
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.

Skilled therapy services are covered when 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.”