It’s common to hear Medicare’s standard for covering skilled nursing care described in part as the patient needing to show a reasonable expectation of improvement. However, it’s important to note that that is not always accurate per the specifics of the Medicare guidelines. The 2012 settlement of the Jimmo v. Sibelius suit, in which Glenda Jimmo challenged her denial for skilled nursing care due to a “lack of improvement”, requires CMS to undertake education campaigns aimed at clarifying how long term care and skilled nursing care claims are to be adjudicated, and to allow for review and redetermination of cases where coverage has been denied due to lack of potential for improvement. However, it’s important to note that CMS is very clear to point out that this is not an expansion or modification of benefits, but a clarification of the standard that has always been in place.
What you need to know:
- If the treatment goal is maintenance to prevent or slow further deterioration, as in the case of a chronic and progressive illness, NO improvement standard should be applied. If care is reasonable and necessary and requires skilled nursing or skilled therapy services, it should be approved. However, if the care can be effectively provided by non-skilled personnel, coverage would not be available.
- If the treatment goal is restorative, as in after an illness or injury, the improvement standard can be applied to evaluate whether the care being requested is reasonable and necessary.
- In all cases, coverage determinations should be based on whether the care is medically indicated, and whether the specific services requested are reasonable and necessary.
- The CMS education program is ongoing, so some providers may initially not believe a service will be covered because they’ve previously had it denied in similar circumstances.
- Original Medicare’s limits on days of skilled nursing care covered are not changed, however this ruling can potentially help clients with Medicare Supplement plans or Medicare Advantage plans access the additional coverage they’re entitled to through those plans.
It’s important to remember that the specific CMS guidelines are sometimes differently worded than the coverage guidelines of specific carriers, and that the Medicare appeals process is there in the instance of what a client believes is an incorrect denial of coverage, whether by a carrier or by Medicare itself.