If you are on Medicare, know someone who is on Medicare, or think that you might someday be on Medicare, then you need to know about the Jimmo Settlement.
Jimmo deals with how long Medicare has to pay for skilled nursing and rehab services for patients. For years, providers (and Medicare auditors) worked under the assumption that Medicare would only pay for skilled nursing and rehab services as long as a patient “showed improvement.” The Improvement Standard was accepted everywhere.
Then a woman named Glenda Jimmo, along with some other folks, filed a class action lawsuit in federal court over the Improvement Standard, and pointed out that the standard was basically an urban myth. It wasn’t stated anywhere in the law.
She had an excellent point, and the federal agency that ran Medicare knew it. So they reached a settlement that set out the new standard. And they agreed to educate health care providers and Medicare auditors on it.
Under the new standard in Jimmo, Medicare has to pay for medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, if the services are needed to maintain the individual’s condition or prevent or slow his or her decline.
The standard is maintenance or slowing decline, not improvement.
Jimmo applies to both Medicare Part A and B. It covers outpatient physical therapy, occupational therapy and speech therapy, and long term home health care. It also applies to Medicare Advantage plans, and covers skilled maintenance services at home, as an outpatient, and in nursing homes.
Unfortunately, the government has fallen down on spreading the word, and lots of providers and Medicare auditors are still applying the wrong standard. On August 17, 2016, the federal district judge issued a new order requiring the government to fix that.
In the meantime – go back and re-read the Jimmo standard above. If this affects you, know your rights. And, by golly, assert them.
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The information contained in this article is general information only and does not constitute legal advice.