Medicare Coverage Fact Sheet

Medicare Coverage
In Light of Jimmo v. Sebelius
For Providers, Contractors, and Adjudicators
Beneficiaries do not have to improve to qualify for Medicare coverage!

On January 24, 2013, a U.S. District Court approved the settlement agreement in Jimmo v. Sebelius, No. 5:11-CV17
(D. VT). As a result of the Jimmo Settlement, the Centers for Medicare & Medicaid Services (CMS) was
required to confirm that Medicare coverage is determined by a beneficiary’s need for skilled care, not on a
beneficiary’s potential for improvement. Medicare policy now clearly states that coverage “does not turn on the
presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled
care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or
to prevent or slow further deterioration of the patient’s condition.” (CMS Transmittal 179, Pub 100-02, 1/14/2014). Read More

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