10 Things about Medicare Policy Change & Jimmo Settlement Agreement


GOOD NEWS for Medicare beneficiaries with long-term, debilitating conditions and those who need rehabilitation services.

These beneficiaries for decades have been denied necessary care based on the “Improvement Standard”. This means denials for vital care to thousands of people on the grounds that their condition was stable, chronic, not improving, or that the necessary services were for “maintenance only.”   Those mostly affected by these denials includes patients with multiple sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease and paralysis.  The lawsuit, Jimmo v. Sebelius, challenged the use of the illegal Improvement Standard.

Caregivers, families, below are 10 things you need to know about Jimmo Settlement agreement. Get more information here.

What Does the Jimmo Settlement Agreement mean?

Medicare coverage is now available for skilled services to support an individual’s condition. Medically necessary nursing and therapy services, provided by or under the supervision of skilled staff, are coverage by Medicare if the services are needed to support the individual’s condition, or prevent or slow their decline.

Can the Jimmo Settlement Agreement help now?

Yes, health care providers should start the maintenance standard now. Patients should discuss the Medicare maintenance standard with their providers to decide if it is applicable to them. Skilled services are covered when they are required to support a patient’s condition, or prevent further deterioration     

Does the Settlement apply to both Medicare Part A and Part B? 

Yes, it does. It covers outpatient physical therapy, occupational therapy and speech therapy, and long-term home health care, which are covered by Part B.   

Does the Settlement apply to both Medicare managed care (Medicare Advantage) as well as to the traditional Medicare program?

Yes, it does.

Does the Jimmo Settlement Agreement only apply to people with certain diseases, diagnoses, or conditions?

No.  The Settlement is not limited to particular conditions or diseases. It applies to anyone who requires skilled services to keep up or slow deterioration regardless of the underlying illness, disability or injury.

Does the Jimmo Settlement Agreement apply to services provided at home or as an outpatient, or only to nursing home coverage?

The Settlement Agreement applies to skilled maintenance services provided in all three care settings – under Medicare home health, outpatient therapy and skilled nursing facility benefits.

Will the Jimmo Settlement allow people to get coverage for physical therapy at home?

Yes it does and includes not only physical therapy but speech and occupational therapies covered under the Medicare home health benefit. Maintenance therapy can be covered under the home health benefit if a qualified therapist is required to make sure the care is safe and effective.

Does the Jimmo Settlement Agreement add to the several days Medicare will cover in a nursing home?

No.  The Medicare law provides for up to 100 days of coverage per benefit period. The Jimmo Settlement confirms that Medicare coverage is available for skilled nursing and therapy that is needed to support a person’s condition or slow deterioration, for nursing home, home health, and outpatient therapy.  However, it does not add to the several days of coverage.

Is the Jimmo Settlement Retroactive?

Yes it is and goes back to the date the case was filed, January 18, 2011. The Agreement establishes a process called “re-review” for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy) because of the Improvement Standard that became final and non-appealable after January 18, 2011. When the government completes revision of its policy and guidelines, and educates Medicare decision-makers, people will be able to get a re-review of these claims.

Will the Jimmo Settlement Agreement cost Medicare too much?

The skilled maintenance nursing and therapy is usually a low-cost, low-tech care that will often prevent the person from declining further and requiring more intense, more expensive care. .

 What are your thoughts? How will the Jimmo settlement agreement impact you, your family and loved ones? Share your story and inspire others!

Dr Goldina Erowele

Dr Goldina Erowele

PharmD, Editor of CareNovate Magazine, Coachcafee.com.
If you'd like to write an actionable health care tip, patient and medication safety post for CareNovate Magazine or Coachcafee.com, then check out our Contribute page for details. We'd love to share caregiver's & patient's experiences with our community.
Dr Goldina Erowele

Share your insights