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CMS Publishes Long-Awaited Guidance on “Maintenance Coverage Standard” Settlement

Posted in Home Healthcare, Hospitals and Institutions, Litigation, Medicare and Medicaid, Reimbursement Matters

On August 24, the Centers for Medicare & Medicaid Services (CMS) published the long-awaited guidance required by the January 2013 Jimmo v. Sebelius Settlement Agreement, 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 that all other coverage criteria are met).

Previously, Medicare carriers and auditors had required evidence that the beneficiary would show clinical improvement in order for the service to be considered medically necessary for coverage. CMS stated, “The Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”

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