Medicare Maintenance Series – Clarifications on what has been called the “Medicare Improvement Standard” have been disseminated by CMS over the past few weeks with an emphasis on the coverage for maintenance services does not turn on the “presence or absence of potential for improvement, but on the need for skilled care as well as the underlying reasonableness and necessity of the services themselves”. As a condition of the Jimmo v. Sebelius Settlement Agreement CMS completed a round of educational activities to providers and contractors alike. The settlement involves skilled care for the SNF, home health, IRF and outpatient therapy benefits.
CMS updated the SNF (Chapter 8), home health (Chapter 7), and outpatient therapy (Chapter 15) sections of the Medicare Benefits Policy Manual, as well as an update on IRF (Chapter 1). In addition released MedLearn Matters Article MM8458, and disseminated Transmittal R175BP to the industry with all relevant updates. A campaign to update contractors, including MACs and Recovery Auditors (RACs) has been undertaken, and a national provider call was held in December.
Jimmo Settlement – No Expansion of Coverage
The settlement agreement itself includes language specifying that “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”
According to CMS the
…intent is to clarify Medicare’s longstanding policy that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. As such, the manual revisions……do not represent an expansion of coverage, but rather, provide clarifications that are intended to help ensure that claims are adjudicated accurately and appropriately in accordance with the existing Medicare policy. Similarly, these revisions do not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must to be reasonable and necessary to diagnose or treat the beneficiary’s condition.
Medicare Improvement Standard
In program materials disseminated prior to the national provider call, CMS clarified that no improvement standard is to be applied in determining Medicare coverage for maintenance claims that require skilled care. And as such skilled nursing or therapy services are covered when the services are needed to maintain a beneficiary’s current condition or prevent (or slow) further deterioration. According to CMS this means that ” the beneficiary must not only require maintenance care but must require skilled involvement in order for the needed care to be furnished safely and effectively.”
Maintenance services when given in the context where no improvement is expected, may be necessary by a beneficiary’s special medical complications requiring that the care be performed by skilled personnel (e.g. physical therapist), for a service that would otherwise be provided by unskilled (aide, tech) personnel.
In summary Medicare has provided manual clarification on medical necessity of skilled maintenance and unequivocally states in the manual updates that this is not an expansion of coverage, but a clarification of existing policy. Stay tuned as we begin a series on the Medicare Improvement Standard and the implication of the Jimmo settlement over the next several weeks. We’d like to know your opinion. Have patients come to your clinic asking for maintenance therapy? Do you have patients on your previous caseload that you would not consider a candidate for skilled maintenance in order to prevent decline?