GRS Regulatory Update: 
CMS Launches Court-Ordered Jimmo Settlement Agreement Webpage

Issued: August 25, 2017


Summary

The Jimmo v. Sebelius case was originally settled by the United State District Court in January 2013 with an additional settlement on February 1, 2017.  This settlement agreement affirmed that Medicare claims for skilled rehabilitation and/or skilled nursing services cannot be denied based solely on a patient’s lack of improvement in condition and/or function.  Rather, the determining factor is the need for skilled service.  The terms of the additional settlement required CMS to further enhance their messaging and communication on this topic by September 4, 2017.   


CMS Action

On August 23, 2017, CMS launched the Jimmo Settlement Agreement website.   Available information on this site includes:


Key concepts of interest addressed in the FAQs include:

·        

  • “The Jimmo Settlement Agreement included language specifying that nothing in the settlement agreement modified, contracted, or expanded the existing eligibility requirements for receiving Medicare coverage.” (Q2)
  • “The Jimmo Settlement Agreement clarified that when a beneficiary needs skilled nursing or therapy services under Medicare’s skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits in order to maintain the patient’s current condition or to prevent or slow decline or deterioration (provided all other coverage criteria are met), the Medicare program covers such services and coverage cannot be denied based on the absence of potential for improvement or restoration.” (Q1) 
  • “Coverage of skilled nursing and skilled therapy services under these benefits does not turn on the presence or absence of a beneficiary’s potential for improvement or restoration, but rather on the beneficiary’s need for skilled care.” (Q4)


GRS Action

The clarifications in this settlement reflect current Genesis Rehab Services (GRS) standards of care and understanding of Medicare coverage.  GRS therapists will continue to assess patients based upon their need for skilled rehabilitation care.


Resources

If you have questions, please contact the Genesis Rehab Services (GRS)/ Respiratory Health Services (RHS) email inquiry system at GRSASK@genesishcc.com.

.

The Regulatory Administration department of GRS/RHS closely monitors legislative and regulatory notices, and continues to work with Congress, CMS and industry leaders regarding changes in government regulations that may impact patient care and service delivery.