Advancing Access to Medicare and Necessary Care for
People with Long-Term Conditions and Injuries
With support from the John A. Hartford Foundation the Center for Medicare Advocacy has created a multi-disciplinary Jimmo Implementation Council. The Center convened the first meeting of the Council on June 23, 2015 at the US Capitol in Washington, DC.
The purpose of the Jimmo Council is to nurture a community of experts committed to working together to implement the Jimmo v. Sebelius Settlement – to open access to Medicare and care for people with long-term conditions and injuries. Council members include beneficiary advocates, providers from numerous care-settings, nurses, therapists, policy-makers, and other stakeholders. At the inaugural Council meeting, members from throughout the country discussed current practices, analyzed successes and barriers, and agreed upon next steps to advance implementation of the Jimmo Settlement.
Background Regarding Jimmo v. Sebelius
Jimmo v. Sebelius was brought in federal court on behalf of a nationwide class of Medicare beneficiaries by six individual beneficiaries and seven national organizations representing people with chronic conditions. The case challenged the use of various illegal improvement standards to improperly limit Medicare coverage for skilled nursing and therapy to maintain an individual’s condition or to slow deterioration. A Settlement was approved by the judge on January 24, 2013 after a fairness hearing, marking a major step forward for thousands of beneficiaries nationwide.
The Jimmo Settlement reiterates that improvement is not required to obtain Medicare coverage for skilled care in Skilled Nursing Facilities (SNF), Home Health care (HH), and Outpatient Therapies (OPT), and to a lesser extent in Inpatient Rehabilitation Hospitals. Coverage does not turn on the presence or absence of potential for improvement, but rather on the need for skilled care.
The Jimmo Settlement is law – agreed to by the federal government and approved by a federal judge. Unfortunately, members of the Council continue to hear about beneficiaries still being denied Medicare coverage and access to care based on an Improvement Standard, spurring the creation of the Council. At the inaugural meeting, Council members discussed the pervasive belief that improvement is required and identified effective methods of countering it, so that Medicare beneficiaries obtain appropriate skilled maintenance nursing or therapy.
Summary of the Jimmo Implementation Council Meeting
At the inaugural meeting, led by Center attorneys and physical therapist Cindy Krafft, the Council discussed how things are working in various care-settings, identified specific barriers to implementation of Jimmo, and considered effective methods to implement the Settlement.
Barriers to Implementation of Jimmo
Barriers for beneficiaries and providers were discussed, including the following:
- Limited educational information provided by the Centers for Medicare and Medicaid Services (CMS) about Jimmo.
- A lack of awareness that Medicare may cover maintenance therapy.
- Widespread myths that improvement is necessary for Medicare coverage and payment.
- Long-held beliefs that improvement is necessary for successful therapy.
- Difficulty understanding the significance of maintenance or stabilization therapy.
- Inadequate literature and data about the benefits of maintenance therapy and the need to avoid deterioration in certain degenerative conditions.
- Limited number of studies to show benefits of maintenance therapy.
- Financial and time-constraint obstacles to document the need for therapy.
- Inadequate clinical practice guidelines to demonstrate the necessity and benefit of maintenance therapy.
- A lack of reference literature to alleviate maintenance documentation concerns.
- Incomplete, or inflexible, Electronic Health Records systems to accommodate individualized patient documentation.
- Difficulty adequately documenting the purpose of maintenance therapy.
- Inadequate corresponding billing codes for time spent on maintenance documentation.
- Limited ability to manually add maintenance therapy descriptions to documentation.
- Concerns about auditing of documentation.
- Annual caps on Medicare coverage, without having to access the exceptions process (currently $1,940 for physical therapy (PT) and speech-language pathology (SLP) services combined, and $1,940 for occupational therapy (OT)).
- Provider reluctance in pursuing exceptions to therapy caps.
- Mandatory manual medical review by Medicare contractors for claims exceeding a threshold of $3,700 (either for PT and SLP combined, or separately for OT).
- Limited Medicare reimbursement for therapy through arbitrary caps and a complicated exceptions process, while not in direct violation of the Jimmo Settlement, undermines beneficiaries’ ability to receive medically necessary maintenance therapy services.
Recommendations for Implementation
Recommendations to implement Jimmo were discussed, including the following:
- Develop more in-depth literature and research studies to produce evidence-based materials.
- Additional CMS education and outreach should be provided, for example:
- More information about coverage of maintenance therapy.
- Add examples of maintenance therapy to Manuals.
- CMS should provide webinars and use other means to disseminate Jimmo-related information.
- CMS should post further Jimmo information on www.medicare.gov (and all official Medicare websites.)
- Jimmo information should be included in the Medicare & You Handbook.
- Other-than-CMS educational outreach, should include, for example:
- Local forums to disseminate information and share maintenance therapy benefits documentation experiences.
- Provider success stories illustrating both challenges and successes in obtaining Medicare coverage.
- Courses and webinars.
- Jimmo information added to Nursing/Therapy school curricula.
- Online continuing educational opportunities for health care professionals.
- Wide distribution of web-based tool kits, to contain replicable documentation, appeals, and other communication templates.
- A briefing on Capitol Hill about Jimmo, possibly on the January anniversary of the Settlement.
- Issue briefs on maintenance therapy and Jimmo.
- Provide numerous materials in “consumer-friendly” language.
- Broadly disseminate all materials.
- Engage in Legislative advocacy, including a demonstration program to:
- Allow waivers for prior authorization of maintenance therapy.
- Mitigate provider risks.
- Engage in Administrative advocacy, including CMS development of appropriate payment codes to cover necessary provider documentation, such as:
- A G-Code for maintenance therapy.
- A CPT code for chronic care management by physicians.
- Create a National Coverage Determination (NCD) for Jimmo (which would serve to eliminate existing inconsistencies in Local Coverage Determinations (LCDs) and communicate the importance of the Settlement).
- Be sure electronic medical record programs include easily accessible choices to record skilled maintenance nursing and therapies.
Council members are committed to working collaboratively to ensure the Jimmo Settlement is fully implemented. Prior to September 30, 2015, Council members will:
- Prepare and post this Summary of the Jimmo Council’s first meeting on this new dedicated page on the Center for Medicare Advocacy’s website.
- Review and share this Summary and other Jimmo Council materials with interested parties to obtain their input, and identify additional recommendations.
- Review existing LCDs to determine if any conflict with Jimmo. If so, inform the Center so they can be submitted to the Jimmo Attorneys for CMS.
- Provide feedback about information posted and desired on the Center’s website regarding Jimmo and the Jimmo Council.
- Assist in developing an in-depth Jimmo Council implementation work plan.
More information about Jimmo is available at: http://www.medicareadvocacy.org/jimmo-v-sebelius-federal-settlement-invalidated-medicare-improvement-requirement/.
 The Center for Medicare Advocacy acknowledges and thanks the leadership and support of the John A. Hartford Foundation and all the members of the Jimmo Implementation Council. We also acknowledge the courage and fortitude of the individual and national organization plaintiffs in Jimmo, including Ms. Jimmo herself, who challenged the use of the Improvement Standard. In addition, we recognize our litigation partners at Vermont Legal Aid, as well as the Atlantic Philanthropies, which funded the work leading to the Jimmo Settlement.
 The Medicare regulations for Inpatient Rehabilitation Hospital coverage (also known as Inpatient Rehabilitation Facilities, or IRFs) include some improvement language. The Jimmo Settlement clarifies that Medicare coverage can be available for patients who need IRF care to adapt to their disability or condition, even if the patient is not expected to return to his or her prior level of function.