maintenance coverage standard

Is Your Skilled Nursing or Therapy Denied for Coverage?

Effective February 16, 2017 the Centers for Medicare and Medicaid Services approved a Corrective Statement to the 2014 Jimmo Settlement Agreement. It reads as follows: The Centers for Medicare and Medicaid Services reminds the Medicare community of the Jimmo Settlement Agreement (January 2014), which 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). Specifically, the Jimmo Settlement required manual revisions to restate a “maintenance coverage standard” for both skilled nursing and therapy services under these benefits.

Many Medicare patients have been told that their skilled nursing and therapy services are based on an Improvement Coverage Standard when in fact that is no longer the case. They have been told that they plateaued in their improvement from the skilled services or didn’t improve fast enough so further coverage is denied. Maintenance Coverage Standard has replaced Improvement Coverage Standard which means Medicare will cover services that are necessary to maintain a patient’s current condition or prevent or slow further deterioration.

Remember to always question a denial for coverage. There may be new regulation or past regulation that has not been communicated or effectively enforced that will be applicable to your specific situation.



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