Answer: No. The Jimmo Settlement confirms that services by a physical therapist, occupational therapist, and speech and language pathologist are covered by Medicare, Parts A and B, and by Medicare Advantage Plans in skilled nursing facilities, home health, and outpatient therapy, when the services are necessary to maintain a patient’s current condition or to prevent or slow a patient’s further decline or deterioration.
Answer: No. As long as the Jimmo Settlement is followed, the patient continues to need professional nursing or professional therapy services to maintain the patient’s condition or to prevent or slow the patient’s decline or deterioration, and all relevant coverage criteria for the particular health care setting are met, Medicare covers the services and the health care provider is not committing fraud.
Answer: No. The Settlement is not limited to any particular condition or disease. It applies to any Medicare patient who requires skilled nursing or skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s further decline or deterioration, regardless of the patient’s underlying illness, disability, or injury. The Settlement is not limited to people with chronic conditions and applies equally, for example, to patients who had a stroke. The fundamental issue for coverage under the standard clarified by Jimmo is whether the patient needs professional services to maintain function or to prevent or slow decline or deterioration.
Answer: The Jimmo Settlement does not include any time limits for Medicare coverage. The rules for the health care settings covered by Jimmo vary.
For home health, as long as the skilled nursing or skilled therapy services are necessary to maintain the patient’s functioning or to prevent or slow the patient’s decline or deterioration, there are no time limits to home health care. Medicare beneficiaries are entitled to ongoing coverage, which may last years, as long as all coverage criteria are met.
There are similarly no time limits for outpatient therapy. Medicare has therapy “caps” for payment for covered services, but there is an exceptions process that authorizes coverage for medically necessary therapy services that exceed the caps. The exceptions process is applicable to maintenance therapy as well as to therapy that is provided with an expectation of improvement.
Coverage for a stay in a skilled nursing facility under Medicare Part A is limited to 100 days in a benefit period for residents needing therapy services five days a week. (Under Part A, Medicare covers room and board, nursing services, therapy services, and medications.) However, if a skilled nursing facility resident has used all 100 days in a benefit period or if the resident needs fewer than five days a week of skilled therapy services, these services can be covered by Medicare Part B. The coverage standards for therapy under Parts A and B are the same. However, Part B payments can continue indefinitely, if coverage standards are met.
Answer: No. The Settlement applies to the entire country. The federal district court judge certified a nationwide class of Medicare beneficiaries.
Answer: No. The Medicare program does not require a patient to decline before covering medically necessary skilled nursing or skilled therapy. If a patient is no longer improving and the basis of Medicare coverage is expected to shift to maintenance, the nurse or therapist must assess the patient and develop a plan of care to reflect the new maintenance goals. The nurse or therapist must document the maintenance goals in the plan of care and in the nursing or therapy notes.
Answer: Yes. Dementia is not a disqualifying condition for Medicare coverage. If the patient needs skilled therapy to maintain the patient’s current condition or to prevent or slow the patient’s decline or deterioration, Medicare covers the therapy services, as long as all other coverage criteria are met. Skilled professional therapists are trained to work with patients who have dementia.
Answer: Maintenance therapy goals include preventing unnecessary, avoidable complications from a chronic condition, such as deconditioning, muscle weakness from lack of mobility, and muscle contractures. Maintenance therapy goals also include reducing fatigue, promoting safety, and maintaining strength and flexibility.
For a patient with a progressive neurologic condition, appropriate maintenance therapy goals include maintaining joint flexibility, preventing contractures, reducing the risk for skin breakdown, and ensuring appropriate positioning.
Answer: Yes. Medicare patients who see health care providers that are participating in a Medicare ACO maintain all their Medicare rights, including application of the clarified standard for coverage of skilled care under Jimmo. Just as with any other Medicare patient, no “rules of thumb” should be used to determine coverage. An individualized assessment of the patient’s medical condition and of the reasonableness and necessity of the treatment is required.
Example: After a hospitalization, a patient receives skilled physical and occupational therapy in a skilled nursing facility for 14 days. While she is no longer improving, she still requires daily skilled therapy to maintain and prevent deterioration, and otherwise meets all coverage requirements. It is appropriate for her to continue to receive Medicare coverage in the skilled nursing facility, regardless of whether her providers are in an ACO. Just as for any other person in Medicare, there is no arbitrary cut-off for coverage in a skilled nursing facility for patients in ACOs. An individualized assessment is necessary, and coverage may continue as long as the patient has a continuing need for skilled therapy or nursing. Note that the maximum of 100 days per benefit period still applies, and that the medical record must support the fact that the patient requires skilled care.
Answer: Yes. Medicare Advantage plans must cover the same Part A and Part B benefits as original Medicare, and must also apply the clarified standard for coverage of skilled care under Jimmo. Just as with any other Medicare patient, no “rules of thumb” should be used to determine coverage. An individualized assessment of the patient’s medical condition and of the reasonableness and necessity of the treatment is required.
Example: After an acute episode a patient in a Medicare Advantage plan is receiving skilled nursing home visits and home health aides covered by her plan. She has congestive heart failure, diabetes, leg and foot ulcers, and, after three weeks, is deemed to be “chronic.” The training and judgment of a skilled nurse are still necessary to monitor, manage, and assess her multiple serious conditions, which have the reasonable potential to change and result in an adverse event. It is appropriate for her plan to continue coverage. The fact that she is “chronic” or in a Medicare Advantage plan is not relevant. Note that all other coverage criteria, such as being “homebound,” must also continue to be met, and the documentation should reflect the reasons why the skilled nursing visits continue to be reasonable and necessary.
Answer: Yes. A patient who is receiving skilled therapy, as outlined in the law, regulations, and Medicare Benefit Policy Manual, requires a discipline-specific, patient-centered care plan. One component of this care plan is goal statements, developed by the qualified therapist and based on an assessment of the patient. The goals reflect the intent and scope of the skilled therapy.
Answer: Since maintenance services are considered skilled care, the patient must meet the setting-specific qualifying criteria outlined in the law, regulations, and Medicare Benefit Policy Manual. Once those criteria have been confirmed, the qualified therapist will, after completion of a thorough assessment of the patient, select the focus of care in collaboration with the physician. If the patient is currently at a point where material improvement is not expected and decline is probable without skilled therapy care, a maintenance course of care may be developed and implemented.
Answer: A patient receiving therapy as outlined in the law, regulations, and Medicare Benefit Policy Manual, is appropriate for discharge from skilled service when the patient no longer requires the skills of an occupational therapist, physical therapist, and/or speech-language pathologist. “Skilled” services are those that can only be provided by a qualified therapist, due to the complex nature of the needed therapy procedures and/or the patient’s special medical complications that require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled.
Answer: There are no specific diagnoses that qualify a patient for maintenance therapy in and of themselves. While patients with progressive neurological conditions, such as Parkinson’s Disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS), are “logical” maintenance therapy candidates, Medicare coverage is not limited to patients with these conditions. Coverage decisions cannot be based on only one piece of information, such as diagnosis. The qualified therapist must consider all relevant information, such as identified impairments and functional limitations, and determine if skilled interventions are essential to stabilize the situation. Per the Medicare Benefit Policy Manual Chapter 7 – Home Health Services; 40.4 – Skilled Therapy Services: “a patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.”
Answer: Yes. Periodic reassessment of both the patient and the plan of care is expected to determine if the course of care is effective in situations where improvement is expected and when it is not. There are setting-specific time frames associated with formal requirements for performing reassessments. These time frames should be considered the minimum standard, as determining effectiveness should be occurring over the entire course of care.
Answer: Yes. Patients determined to be appropriate for maintenance therapy service(s) require assessment by a qualified therapist. This assessment, as with patients receiving therapy services under an improvement (restorative or rehabilitative) focus of care, should include a baseline quantification of impairments. When available and appropriate, the inclusion of objective tests and measures should be utilized to quantify impairments. Objective tests and measures provide valid and reliable findings that demonstrate the effectiveness of therapy and support clinical decision-making regarding continuation or discharge from therapy service(s).
The presence or absence of change in objective tests and measures from baseline to subsequent assessments may vary, depending on whether the patient is on an improvement (restorative/rehabilitative) or maintenance (stabilization) course of care.
Answer: No. A maintenance focus of care does not require all disciplines to take the same approach. Once setting-specific qualifying criteria are met, each individual discipline creates a care plan specific to that discipline. Based on the assessment and periodic reassessment findings, each discipline will choose the most appropriate approach for the patient and must provide documentation that clearly supports that decision.
Answer: Yes. When it is determined by the qualified therapist that a patient requires continued skilled service and the expectation of improvement is no longer indicated, however, it may be appropriate to transition from an improvement approach to a maintenance course of care. This decision would be based on a reassessment of the patient by the qualified therapist at that point, with expectation that modification and/or updates to the existing therapy care plan, in coordination with the physician, occur prior to that transition.
Answer: Yes. A patient may need maintenance therapy to maintain strength and flexibility and to prevent deconditioning while, for example, recovering from surgery or healing from an amputation. Following the recovery or healing, the patient may then become able to participate in additional therapy, with the goal of improving. A patient who is not weight-bearing may need maintenance therapy to maintain strength and flexibility and to prevent deconditioning, but once the patient becomes weight-bearing, she may need additional therapy to regain her ability to walk.
Answer: Yes. “Progress” is not synonymous with “improvement.” Progress in maintenance therapy would be the responsiveness of the patient to the established course of care. Maintenance therapy is intended to stabilize or slow the natural course of deterioration with a progressive condition, or to prevent potential sequelae that may occur due to the presence of that progressive condition, such as soft tissue contracture due to limb paralysis.
Progress, or responsiveness to therapy, would be determined by the patient’s capacity to function at an optimal level, consistent with the stage or severity of the underlying progressive condition.
Answer: Yes, if the patient is under a home health plan of care and at least one qualifying professional service is being provided, aide services can be included as indicated, whether the focus of care is improvement or maintenance.
Answer: No. “Rehab potential” is not a prognosis of the patient’s underlying condition(s), but rather the qualified therapist’s clinical assessment of the patient’s ability to progress/be responsive to the maintenance therapy program (see answer #20 above). A patient with a progressive condition, such as multiple sclerosis or amyotrophic lateral sclerosis (ALS), would be expected to be responsive to the individualized, patient-centered maintenance therapy care plan developed by the qualified therapist following assessment.
Answer: No. The ability to walk a specified distance is not the sole goal of physical therapy. Physical therapy ensures that the patient can safely navigate the patient’s own actual and personal environment. Mobility and maintenance goals are tied to the patient’s environment. Relevant factors for therapy in home care, for example, may include whether the patient needs to climb stairs to enter the home, whether the patient’s home has one floor or more, and whether the patient needs to navigate curbs and different surfaces.
Answer: No. As long as the skilled nursing or skilled therapy services are necessary to maintain the patient’s functioning or to prevent or slow the patient’s decline or deterioration, there are no time limits to home care. Medicare patients are entitled to ongoing coverage, which may last years, as long as all coverage criteria are met.
Answer: Observation and assessment of the patient’s condition are 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 patient requires skilled care for the services to be safely and effectively performed. Depending on the unique condition of the patient, these services may continue to be reasonable and necessary for a patient for so long as there is a reasonable potential for complications, and all other coverage requirements are met. Coverage does not depend on the patient’s restoration potential, and changes to the treatment plan or the patient’s condition are not required. A patient may appear to be chronic or stable, but because of a reasonable potential for complications, the patient may continue to require skilled care to maintain his or her condition, or to prevent or slow his or her deterioration.
The determination of coverage for maintenance nursing should be made based on the individualized assessment of the patient’s overall medical condition, and the reasonableness and necessity of the treatment, care, or services in question.
Answer: Yes. The Jimmo Settlement allows patients who are engaged in an outpatient therapy program to continue receiving coverage for those services, even if there is no improvement and if the patient will not return to his or her prior level of function if skilled therapy continues to be needed to maintain the individual’s condition or slow decline.
In addition, even though it may appear that the skills of a therapist are not ordinarily required to perform the specific procedures, skilled therapy is covered if the patient’s special medical complication requires the skills of a therapist to ensure proper healing and non-skilled individuals could not safely and effectively carry out the procedures.
The Jimmo Settlement specifically states that skilled therapy services are covered when the specialized judgment, knowledge, and skills of a qualified therapist are necessary for performance of a maintenance program. If the non-skilled personnel cannot ensure the maintenance of the patient’s condition, therapy is reasonable and necessary.
Answer: Yes. The Jimmo Settlement allows patients to receive Medicare coverage for necessary outpatient therapy maintenance programs by skilled providers. Medicare is available when the therapy is required to maintain the patient’s functioning and requires a qualified therapist to be safe and effective. In such circumstances, the provider should seek an “exception” to the therapy cap to continue therapy services. In addition, patients who exceed the $1920 therapy cap or the $3,700 threshold of manual medical review (in 2017) for therapy expenditures can seek a further review to determine whether the outpatient therapy services continue to be reasonable and necessary.
Example: A patient with Parkinson’s Disease who maintains his current function through regular outpatient physical therapy and speech language pathology should seek an exception to the therapy cap (through his provider) once the cap is reached.
Answer: Yes. The Jimmo Settlement states that the establishment of a maintenance program by a qualified therapist and the instruction of the patient regarding a maintenance program is covered to the extent the specialized knowledge and judgment of the therapist is required. As there may be certain exercises and treatments the patient can learn through the skills of the therapist, a one-time consultation would be covered.
Example: A patient with arthritis that causes difficulty with ambulation may require an outpatient therapy session to learn targeted exercises he can do on his own to improve his walking.
Answer: Yes. Under the Jimmo Settlement, Medicare coverage for outpatient therapy depends on the patient’s need for skilled care by a qualified therapist. The beneficiary’s potential for improvement is not the determining factor for coverage. Therapy to maintain a patient’s condition or to prevent or slow further deterioration is covered if the therapeutic procedures require a qualified therapist to be safe and effective. The issue to determine coverage is not whether the patient improves, but whether the patient requires skilled services. Slowing a patient’s decline or deterioration is an appropriate goal of maintenance therapy.
Example: A patient with diabetic neuropathy and a recent lower limb amputation who receives outpatient therapy to prevent further decline in her mobility but still experiences a decline following initiation of the therapy services is still covered for the care under Medicare if, without the therapy, the patient’s mobility would decline more markedly or rapidly.
Answer: Yes. Under the Jimmo Settlement, necessary periodic reevaluations of maintenance programs by a qualified therapist are covered to the degree that the specialized knowledge and judgment of the therapist are required. A reevaluation of a maintenance program to assess for the need for assistive devices and to prevent deterioration is a skill that requires the specialized knowledge of a therapist. If the therapist determines that the program needs revision, based on the patient’s new developments, the establishment of a new maintenance program would also be covered.
Example: A patient with functional and cognitive deficits following a traumatic brain injury who carries out therapy on his own as part of a maintenance plan may have his therapy plan reevaluated either (1) on a periodic basis to ensure that it is properly addressing his needs or (2) following some change in his condition that may necessitate corresponding changes to the therapy program.
Answer: Medicare covers a maximum of 100 days in a Part A benefit period. If a skilled nursing facility resident has used all 100 days or if the resident needs fewer than five days a week of skilled therapy services (and does not need skilled nursing seven days per week) and if the resident, in either situation, continues to need skilled therapy services, these services can be covered by Medicare Part B. While the coverage standards for Parts A and B are the same, Part B payments for skilled therapy can continue indefinitely, if coverage standards are met.
Answer: Yes. The physician may order therapy to maintain a patient’s strength and flexibility, and to prevent deconditioning, until such time as the patient becomes weight-bearing and can safely participate in additional therapy. Similarly, a patient who needs to learn to use a prosthesis may receive maintenance therapy at the beginning of his or her stay in a skilled nursing facility in order to maintain upper body strength while the site of the amputation heals. Maintenance therapy may be provided first in these situations, followed by therapy to improve the patient’s functioning, once the patient becomes weight-bearing or the patient’s site of amputation has healed.
Answer: Yes. Under the Jimmo Settlement, a Medicare patient’s claim for inpatient rehabilitation hospital care cannot be denied simply because the patient is not expected to return to his or her prior level of functioning. While the IRH regulations do include a modified improvement standard, the patient must only be reasonably expected to make measurable improvement that will be of practical value to improve the patient’s functional capacity or adaptation to impairments. The expected improvement is to be accomplished within a reasonable period of time. Therefore, as long as there is a reasonable expectation that the patient can make some improvement in functional status, it is not required that the patient be able to return to his or her prior level of functioning.
Example: If a patient who required amputation of a lower limb is not expected to be able to return to her pre-amputation functional status, IRH care may still be reasonable and necessary if the rehabilitation physician believes that she will make measurable improvement of practical value and all other coverage criteria are met.
Answer: Yes. The Jimmo Settlement states that inpatient rehabilitation claims cannot be denied based simply on the fact that a patient can never achieve complete independence with self-care. In an IRH, a patient’s medical record only needs to demonstrate a reasonable expectation that a measurable improvement will be possible within a reasonable period of time. The patient’s medical record must indicate the nature and degree of expected improvement and the expected length of time to achieve the improvement in order to properly track whether an inpatient rehabilitation stay is reasonable and necessary.
Example: If it is clear that a Medicare patient who has experienced a traumatic brain injury will not be able to be fully independent with self-care at the conclusion of therapy services, an IRH stay may still be medically reasonable and necessary, and covered by Medicare, if measurable improvement of practical value to the individual can be reasonably expected.
Answer: No. There are no distinctions between Medicare IRH coverage criteria applicable to patients with one of the 13 qualifying conditions for IRH classification versus other patients. Jimmo does not apply only to a particular set of diagnoses, conditions, injuries or illnesses.
Example: A patient with cancer of the spine (which is not one of the 60% qualifying conditions) may need inpatient rehabilitation, and Medicare coverage, to address deteriorating function in conjunction with his health issues. The premise of the Jimmo Settlement applies equally to such a patient as to patients who have a condition on the 60% list. The 13 qualifying conditions are intended to determine whether a hospital or unit qualifies for classification as an IRH, not whether IRH care for a particular patient qualifies for Medicare coverage.
Answer: Yes. In order for the patient to receive a Medicare-covered inpatient rehabilitation stay, the patient’s medical record must demonstrate ongoing and sustainable improvement that is of practical value to the patient. However, if the expectation for measurable improvement existed at the time of the patient’s admission and can realistically be documented in the medical record even after no initial improvement, it is possible the IRH stay may be covered.
Example: If a formerly independent, debilitated patient does not make measurable improvement within the first seven days of an IRH stay but the physician documents the continued expectation for measurable improvement of practical value, with support from the medical record, Medicare coverage can continue.
Answer: No. The entire stay should not necessarily be denied coverage as long as, when the patient was admitted, the medical record demonstrated a reasonable expectation that there would be a measurable, practical improvement in the patient’s functional condition over a predetermined and reasonable period of time. If the patient does not achieve a measurable improvement by the expected period of time, and the physician no longer has an expectation that the patient would improve, any further inpatient care would no longer be covered. However, as long as there was an expectation of improvement during the inpatient stay, regardless of whether there was actual improvement at any time, the stay can be covered as necessary and reasonable.
Example: If a patient who had a stroke was initially determined to be appropriate for IRH care but then did not progress during the stay and was determined by the physician at the first team meeting to no longer have a reasonable expectation of improvement, subsequent days, but not the prior period, (following a reasonable amount of time to arrange for transfer or discharge) would no longer be covered.
Answer: Yes. The Jimmo Settlement states that daily physical improvement is not required to retain covered services. This is true even in an inpatient rehabilitation setting, as the requirements for improvement are only measured over a prescribed period of time. During a long stay, many treatment plans will move from traditional therapeutic services to patient education, equipment training, and other similar instruction to prepare patients for the return home. The counseling and instruction towards getting the patient ready to go home are considered part of the therapy and meet the end goal of enabling the patient to safely live at home.
Example: If a patient who had a stroke and was admitted to an IRH for treatment improves to the point of being medically and functionally ready for discharge, she may receive Medicare for several more days in the IRH if those days are necessary to counsel and instruct the patient (and her caregivers) regarding safely returning to home and home exercise programs or use of mobility equipment.
Answer: Yes. Pursuant to the Jimmo Settlement, Medicare coverage for IRH care should not be denied because a patient is not expected to achieve complete independence in the domain of self-care or because a patient is not expected to return to his or her prior level of functioning. In addition, the IRH regulations state that Medicare will only cover an IRH claim if the patient is expected to make a measurable improvement that will be of practical value to improve the patient’s functional capacity or adaptation to impairments. Even though the IRH regulations require an expected measurable improvement, if the stay is for the purpose of the prevention of deterioration, the expected prevention of deterioration itself is a measurable improvement over what the patient’s function would have been if he or she had not been admitted for an inpatient stay. In addition, Medicare coverage can be available if the patient makes an expected, measurable improvement to improve his or her adaptation to impairments. Therefore, assuming the other coverage criteria are met, the stay can be covered by Medicare.
Example: A medically compromised patient with a long-term spinal cord injury who starts to have increased difficulty performing activities of daily living despite a maintenance therapy program may be appropriate for IRH care if his physician has a reasonable expectation that inpatient therapy will prevent the patient’s further deterioration, thereby achieving measurable improvement of practical value for the patient.
Filed Under: Article Tagged With: The Improvement Standard