Feb. 15, 2024

News from LeadingAge: MA Plans Can’t Terminate Skilled Care Because Beneficiaries Don’t Improve

On February 15, 2024 by LeadingAge

LeadingAge, along with its coalition partners on Medicare Advantage (MA), asked CMS to clarify that MA plans must follow Medicare regulations related to the Jimmo Settlement Agreement (2013) when making coverage determinations.

In a Feb. 13 CMS memo, MA plans were reminded to  “refresh and/or train staff and contracted providers” on this policy, “which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration …”

CMS noted that there may be a misconception that the Medicare program only covers nursing and therapy services under Medicare when a beneficiary is expected to improve. This is another win for LeadingAge on its MA advocacy efforts.

LeadingAge members have reported that MA plans frequently terminate skilled services due to “failure to progress” or because an individual “shows no improvement.” This memo makes clear that plans cannot terminate care for this reason because Medicare regulations support an individual’s need for skilled care to maintain their function and/or slow their decline.

Further, CMS’ instructions to the plans to retrain their staff and contractors on this requirement is important, and should indicate that they will be watching for compliance going forward. CMS also updated its Medicare webpage to remind all providers that under the Jimmo Settlement, CMS was required to update its Medicare manual to “restate a ‘maintenance coverage standard’ for both skilled nursing and therapy services,” and as such, skilled nursing services are covered when “necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary required skilled care for the services to be safely and effectively provided.” CMS includes a number of resources related to the Jimmo Settlement here for further information.