New Medicaid Regulations for Skilled Care

I have previously written about the gratifying verdict obtained by the Center for Medicare Advocacy in Jimmo vs. Sebelius earlier this year. This verdict ended the longstanding practice of denying Medicare coverage to people whose conditions had “plateaued,” or were “chronic,” or “stable,” or “not likely to improve.” even if they still needed that therapy to prevent their condition from declining.

The verdict has now been incorporated into revisions to the Medicare Policy Manual published by the Centers for Medicare and Medicaid Services (CMS) on December 6, 2013. The new regulations, which apply to care in Inpatient Rehabilitation Facilities, Skilled Nursing Facilities, Home Health care and Outpatient Therapies, clarify that improvement is not required to obtain Medicare coverage.

As CMS states in the Transmittal announcing the Jimmo Manual revisions:

“No ‘Improvement Standard’ is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). The Medicare statute and regulations have never supported the imposition of an “Improvement Standard” rule-of-thumb in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves. The manual revisions now being issued will serve to reflect and articulate this basic principle more clearly.”

Source/more: Center for Medicare Advocacy

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