CMS Updates Medicare Policy Manuals for Skilled Nursing Services

CMS Updates Medicare Policy Manuals for Skilled Nursing Services

In a previous blog post, I alerted you to the settlement of a federal lawsuit entitled Jimmo v. Sebellius, in which the Center for Medicare and Medicaid Services (CMS) denied that there ever existed a so-called “improvement standard” for the coverage of nursing home under Medicare. Rather, CMS agreed that such coverage would be determined by the resident’s need for skilled services, not on his or her potential for improvement.

As also discussed in that post, the settlement in the Jimmo case was only the beginning of potential relief for nursing home residents in this situation. The problem was—and remains—that this belief that skilled nursing home services under Medicare ceases when a nursing home resident has “plateaued” is deeply ingrained in the practices of nursing homes.

That is why nursing home residents seeking coverage under Medicare welcome news, announced January 14th, that CMS has revised its Medicare Benefit Policy Manual. Quoting from the announcement:

In accordance with the Jimmo v. Sebelius Settlement Agreement, the Centers of Medicare Medicaid Services (CMS) has agreed to issue revised portions of the relevant program manuals used by Medicare contractors, in order to clarify 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”. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

This is a huge revision to the source of guidance—the Medicare Benefit Policy Manual—actually used by nursing homes.  Predictably, since the approval of the Jimmo settlement over a year ago, families continue to report to us that words like “plateaued” and “no further improvement” are used by nursing homes to explain why continued Medicare coverage for skilled nursing services is denied.  Now that the Manual actually used by nursing home service providers has been used, nursing home residents will be able to get the full extent of Medicare coverage to which they are entitled.


Mark Heffner

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