New Improvement Standard Changes in the Medicare Manual
Tuesday, December 10, 2013
by: VNAA Advocacy Team

Section: Public Policy and Advocacy




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On Dec. 6, 2013, the Centers for Medicare and Medicaid Services released an important transmittal: Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius. CMS revised the Medicare Manual to reflect the outcome of the Jimmo v. Sebelius settlement on the Improvement Standards. Specifically, CMS clarifies that coverage of skilled nursing and skilled therapy services "...does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care."

The full Transmittal can be found here.

The key points of the manual changes include:

  • No “improvement standard” is to be applied in determining Medicare coverage for maintenance claims for skilled care.
  • Guidance on appropriate documentation
  • Language clarifying that the Jimmo v. Sebelius settlement is not a coverage expansion; Medicare’s covers skilled services when required on order to provide care that is reasonable and necessary to prevent of slow deterioration. Coverage cannot be denied based on the absence of the potential for improvement.
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