Jimmo v. Sebelius Settlement Agreement
AmeriHealth Caritas VIP Care Plus wants to remind our Medicare provider community of the settlement reached in January 2013 in Jimmo v. Sebelius. The Jimmo Settlement Agreement 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 Agreement required revisions to the Medicare coverage manual to restate a "maintenance coverage standard" for both skilled nursing and therapy services under these benefits:
- Skilled nursing services will 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.
For additional information and training resources please refer to the documents below:
- Clarified summary of question responses (PDF)
- Fact Sheet (PDF)
- Manual Update - Change Request 8458 (PDF)
- Manual Update - Change Request 8644 (PDF)
- MLN Matters - MM8458 (PDF)
- National provider conference call (MP3)
- National provider call transcript (PDF)
- Settlement agreement (PDF)
- Settlement agreement presentation (PDF)
- Settlement agreement program manual clarifications (PDF)