You may recall reading about the Jimmo v Sebelius case in 2013, which settled once and for all that the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will “improve.” Previously, medically-necessary nursing and therapy services, provided by or under the supervision of skilled personnel, were coverable by Medicare if the services were needed to maintain the individual’s condition, or prevent or slow the individual’s decline.
AAPM&R worked with the Center for Medicare Advocacy to win the settlement in the Jimmo v Sebelius lawsuit and end the practice of requiring that patients are likely to improve before Medicare will pay for therapy or skilled nursing services. The Center for Medicare Advocacy went to court in the spring of 2016 to urge the judge to require the Centers for Medicare & Medicaid Services (CMS) to provide more education, as required by the settlement. As of August 18, 2016, the judge has ordered that CMS comply with the settlement agreement that was approved in 2013, and that they must provide more education. The hope is that this will open more doors to Medicare and necessary care for people with long-term and debilitating conditions. View the full press release here.