Medicare Coverage In Light of Jimmo v. Sebelius For Providers, Contractors, and Adjudicators

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With support from The John A. Hartford Foundation, the Center for Medicare Advocacy has produced a new Fact Sheet to help Medicare providers, contractors, and adjudicators apply the correct legal standard to Medicare coverage and payment determinations – as required by the Jimmo v. Sebelius Settlement Agreement.

The Jimmo Settlement means that Medicare coverage and payment are available for care  provided in a skilled nursing facility, home health  or outpatient therapy setting when skilled nursing or therapy is required to maintain or slow decline of an individual’s condition. The determination of whether Medicare is available turns on whether skilled personnel must provide or supervise the care for it to be safe and effective, not on whether the care is intended to improve the individual’s condition. Medicare-covered skilled care includes care that improves, or maintains, or slows the decline of a patient’s condition.

The Jimmo Fact Sheet includes links to materials written by CMS and approved by the Jimmo Court; these materials represent official Medicare policy. The Center for Medicare Advocacy urges providers, contractors, and adjudicators to utilize these resources whenever Medicare coverage and payment decisions are made.

Download the Fact Sheet

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