Program Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. Sebelius


On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius,  involving skilled care for the inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits. “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

The goal of this settlement agreement is to ensure that claims are correctly adjudicated in accordance with existing Medicare policy, so that Medicare beneficiaries receive the full coverage to which they are entitled. The settlement agreement sets forth a series of specific steps for CMS to undertake, including issuing clarifications to existing program guidance and new educational material on this subject.

As part of the educational campaign, this MLN Connects™ Call provides an overview of the clarifications to the Medicare program manuals. These clarifications reflect Medicare's longstanding policy that when skilled services are required in order to provide reasonable and necessary care to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. In this context, coverage of skilled nursing and skilled therapy services “…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.” Portions of the revised manual provisions also include additional material on the role of appropriate documentation in facilitating accurate coverage determinations for claims involving skilled care.

More information is available in MLN Matters® Article #MM8458 (PDF), “Manual Updates to Clarify SNF, IRF, HH, and OPT Coverage Pursuant to Jimmo v. Sebelius.”

When: Thursday, December 19, 2013

Time: 2:00 PM - 3:00 PM Eastern Time

Target Audience:  Skilled Nursing Facilities; Inpatient Rehabilitation Facilities; Home Health Agencies; and providers and suppliers of therapy services under the Outpatient Therapy Benefit.


  • Clarification of Medicare’s longstanding policy on coverage for skilled services
  • No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required
  • Enhanced guidance on appropriate documentation

Call Materials:

Slide Presentation (PDF)

Audio Recording (ZIP)

Written Transcript (PDF)