Jimmo Revisited: Improvement vs. Need Medicare Standard

You need to know about Jimmo because many Medicare providers, suppliers, and adjusters are clueless.

So says a 2018 report from the Centers for Medicare & Medicaid Services.

Jimmo is the name for a 2013 settlement arising from a federal lawsuit over Medicare coverage for skilled nursing care and skilled therapy services.  The Jimmo agreement restated the standard for providing continued services.  Providers and suppliers who do not know about Jimmo are prone to wrongfully cut off services and refuse to supply equipment because, frankly, they are applying the wrong standard.

That is where you come in. You have to know the basics so you can fight a wrongful denial.

So here are the basics:

Medicare provides services for skilled nursing or therapy to a “beneficiary” under its skilled nursing facility, home health, and outpatient benefits.  The beneficiary has to initially qualify for the benefits, including meeting the requirements that the services be reasonable and necessary, comply with therapy caps and not exceed the 100- day limit for Part A SNF benefits during the benefit period.

Here is where Jimmo comes in:

Medicare cannot refuse to provide these benefits merely because the beneficiary has no potential for improvement.  It simply does not matter whether the care is expected to improve or maintain the beneficiary’s clinical condition.

For services furnished in an Inpatient Rehabilitation Facility or a comprehensive outpatient rehabilitation facility, Jimmo clarifies that coverage should never be denied merely because the beneficiary cannot be expected to achieve complete independence of self-care or return to a prior level of functioning.

Because of Jimmo, nursing and therapy services must be provided to maintain the beneficiary’s condition or prevent or slow further deterioration.  Coverage turns on the beneficiary’s need for skilled care.

To qualify for coverage, the beneficiary must have an individualized assessment of his or her medical condition and the reasonableness and necessity of the treatment, care or services.

To get that, a health care provider must do the evaluation.  Here is where it gets a bit tricky.  The health care provider has to keep adequate documentation.  Cryptic notes such as “patient tolerated treatment well,” “continue with POC,” and “patient remains stable” won’t cut it.

Beneficiaries will have to continue obtaining evaluations throughout their treatment.

The Jimmo standards also apply to Medicare patients whose health care providers are in Accountable Care Organizations and to beneficiaries of Medicare Advantage plans.

If you have questions, there are several good resources available.  The beneficiary helpline is at  1-800-MEDICARE.  A CMS question and answer sheet can be found at https://www.cms.gov/Center/Special-Topic/Jimmo-Settlement/FAQS.html.

A general discussion can be found at https://www.cms.gov/center/special-topic/jimmo-center.html.  That website also provides you with a link to the text of the Jimmo Settlement Agreement.

If you want to dazzle your provider, then casually mention the Medicare Benefit Policy Manual (100-02) and state he or she needs to brush up on Chapters 7, 8 and 15 and then come back and discuss it with you.

Knowledge is power.  Now that you have it, use it.

Virginia Hammerle is a licensed Texas attorney.  Her practice includes estate planning, litigation, guardianship, and probate law.  See hammerle.com for her blog and newsletter sign-up.  This column does not constitute legal advice.