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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.

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