Medicare Reimbursement for Skilled Rehab Therapy

New Issue Brief: Implementing Jimmo v. Sebelius: An Overview -

In 2013, a federal district court approved a settlement agreement in Jimmo v. Sebelius, No. 5:11-CV-17 (D. VT). The Jimmo Settlement confirmed that Medicare coverage should be determined based on a beneficiary’s need for skilled care (nursing or therapy), not on the individual’s potential for improvement. The Jimmo Settlement and court decisions pertain to all Medicare beneficiaries throughout the country and apply regardless of whether an individual is in traditional Medicare or a Medicare Advantage plan.

Unfortunately, more than six years after the Settlement’s approval, the Center still regularly hears from Medicare beneficiaries and providers about problems with its implementation in home health, skilled nursing facility, outpatient therapy, and inpatient rehabilitation hospital settings across the country.

In the face of enduring barriers to Medicare-covered care, and with support from the John A. Hartford Foundation, the Center compiled this Issue Brief to provide Medicare stakeholders with an overview of the Jimmo Settlement, what it means in different care settings, some of the Center’s key implementation work, and links and references to helpful resource materials. The Center hopes this information will help Medicare beneficiaries, families, providers, contractors, adjudicators, and other stakeholders learn about the principles articulated in Jimmo and access relevant resources to ensure the Settlement is properly implemented.

The Issue Brief includes:

  • The Jimmo Settlement & Corrective Action Plan

  • Home Health Coverage In Light of the Jimmo Settlement

  • Skilled Nursing Facility Coverage In Light of the Jimmo Settlement

  • Outpatient Therapy Coverage In Light of the Jimmo Settlement

  • Inpatient Rehabilitation Hospital/Facility Coverage In Light of the Jimmo Settlement

  • The Jimmo Implementation Council

  • Efforts to Improve Implementation

  • Next Steps

  • Important Resources from the Center

The full Issue Brief is available at: https://www.medicareadvocacy.org/wp-content/uploads/2019/06/Jimmo-Improvement-Standard-Issue-brief-June-2019.pdf

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