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CMS clarifies “Improvement Standard” to the benefit of persons served

CMS clarifies “Improvement Standard”

by Alexandra Bennewith, M.P.A., Vice President, Government Relations and Jane Wierbicky, RN, Information Specialist, United Spinal Association

Photos of Alexandra Bennewith and Jane Wierbicky Recent CMS actions provide welcome clarity to providers, insurers, and individuals with chronic conditions who need rehabilitative therapies and other skilled services, even when their underlying condition will not improve.

The actions were prompted by a class-action lawsuit and a 2017 court order. They include revisions to the Medicare Benefit Policy Manual, a CMS webpage devoted to the topic, and a nationwide education campaign.

At issue was interpretation of Medicare’s “Improvement Standard,” which previously operated as a rule of thumb to terminate or deny Medicare coverage to beneficiaries who were not improving. Before the clarification, Medicare regulations were incorrectly interpreted as not covering skilled nursing or skilled therapy services when a beneficiary needs skilled care to maintain their condition.

Although the original lawsuit, Jimmo v. Sebelius, was settled five years ago, confusion persisted, often creating barriers to skilled services for those who needed them.

Here’s a summary of recent clarifications and actions impacting treatment access for individuals with spinal cord injury and other paralyzing conditions:

  • Maintenance-coverage standard: Medicare coverage is available for skilled services to maintain an individual’s condition. Medicare coverage turns on whether the skilled services of a healthcare professional are needed, not whether the Medicare beneficiary will “improve.”
  • Medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual’s condition or prevent or slow their decline. In other words, maintenance services can be skilled, performed by a skilled therapist or nurse, and covered by Medicare.
  • CMS must develop and implement a nationwide education campaign for all who make Medicare determinations to ensure that beneficiaries with chronic conditions are not denied coverage for critical services because their underlying conditions will not improve.

A Jimmo webpage on the CMS site,, was released in August as the court required.

The page includes helpful information and resources for providers, adjudicators, and contractors. It clarifies coverage for skilled nursing facilities, home health, and outpatient services related to Jimmo, and includes an FAQ section. Click on the Medicare Benefit Policy Manual link in the page’s lower right to access manual revisions, which are formatted in red italic font to make them easier to find. The revisions offer enhanced guidance on goal setting and provider documentation to meet requirements.

With these updated resources, providers can clearly understand CMS reimbursement policies for services designed to meet the functional needs and abilities of those they serve.

United Spinal Association is a member of CARF’s International Advisory Council.

(Medical Rehabilitation)

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