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The Improvement Standard

Have you ever been told that no matter how sick your patient is, the Medicare Home Health Benefit does not cover chronic care?  If you are my client, you have and I certainly didn’t make it up.

As it turns out, CMS has identified the need to offer a little clarification on that requirement.  Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the “Improvement Standard” case, Jimmo v. Sebelius.

In a Nutshell

Skilled Nursing and Therapy services may be provided to a patient to maintain the patient’s present condition or prevent further deterioration if:

The skilled services are of sufficient complexity to require the skills of a nurse or therapist

The individualized assessment does not indicate that the services can be performed safely by an unskilled person

Effective Date

The effective date of this ‘change’ January 18, 2011 which is the date the lawsuit was filed.

Because the practice of denying beneficiaries who would benefit from skilled services to maintain their current condition or prevent further deterioration has never been legal, this isn’t an actual change in coverage.  It was merely a little misunderstanding and as noted, clarity from CMS is on the way along with an Educational Campaign for providers, contractors and adjudicators.

If you have been denied for claims related to a patient’s failure to show improvement since January 2011, appeal them.  Fill out a reconsideration form and attach the text of the settlement agreement.


In order to qualify for maintenance skilled services, the document emphasizes repeatedly the need for an ‘individualized’ assessment to reflect the needs.  Be careful in offering long term services on a routine basis but never discharge anyone who requires continuing skilled care.

This requirement will not be met by offering long term packaged skills provided as a result of a generic assessment.  You will be denied if you routinely offer ongoing range of motion services to all stroke patients.  You may be covered if a stroke patient has an orthopedic defect that would render range of motion to be a high risk endeavor for an unskilled person.

More Information

Visit the Center for Medicare Advocacy for more information.  And leave a comment about how you think the Improvement Settlement will affect your agency.

2 Comments Post a comment
  1. Gail #

    I am stunned. One of the few common sense moves by your government and mine that I can recall is really happening. Many of our patients have chronic progressive diseases and may improve in the short term, but who expect deterioration of their conditions in the long term. Chronic kidney disease comes to mind. Even with excellent medical and nursing care, CKD patients are going to deteriorate; and I believe more quickly without home health services. I also believe that many people who have to go to nursing homes can now remain at home longer and perhaps never have to go to a nursing home. We have cancer patients who are not going to get better and fight till the bitter end that we can care for if they don’t want Hospice for whatever reason.
    Yes, I have felt like pond scum before. I had to tell a precious old gentleman that his HMO would not approve reimbursement for his care and that we were appealing this decision. A few days later, we heard that he was in an acute care hospital on “life-support” and wasn’t expected to live. Could we have prevented this? We’ll never know will we? Not that money talks and BS walks, but how much $$$$$ did his HMO shell out for his extended stay in an ICU? A lot more than they would have paid for HH to care for him, I’ll bet. We found out that he did survive and his caregiver elected another home health after being discharged home after a lengthy stay in the hospital; but we’re really glad that he is getting care at home and wish him all the best.
    Again, thanks for sharing this important news with everyone.

    October 30, 2012

    • I just basically blew off a boatload of denials for a patient with a bizarre, progressive neuromuscular disease that caused torsion and very painful spasms. Pt was ver weak and fragile. A lay person could have easily caused greater harm to this patient. Therapist went out and provided relief through massage and range of motion. Claims were denied because she was not getting better. I filled out recon forms anyway just to keep all denials in the same status. I think I might add a little settlement agreement to the denials. Yeah. That’s what I will do.

      October 30, 2012

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