Jimmo Settlement

Jimmo! There seems to be difficulty for families in discerning what Jimmo can mean for Medicare out patient therapy coverage versus Medicare rehabilitation coverage.

Jimmo was a 2013 class action settlement with DHHS when Kathryn Sebelius was its head. The lead plaintiff, Jimmo, was diabetic, blind, amputee on Medicare for health insurance and receiving both in-home care and out-patient therapy (OPT skilled care done by PT, OT, ST). MediCARE had covered her inhome & OPT for years but stopped due to MediCARE applying “improvement standard” for determining whether Medicare would pay.

Jimmo was the lead plaintiff but others in the class were primarily ALS and MS living at home. A somewhat different population than those in a SNF / NH as long term custodial care resident or those in a SNF / NH as a limited term rehabilitation patient.

Jimmo settlement requires Medicare to look at certain standards beyond “improvement” alone for claim determination. Those who can benefit for skilled services for maintenance or to prevent or slow decline or deterioration, now under Jimmo settlement, as Medicare beneficiaries are entitled to coverage. It is a different benefit coverage than Medicare paying for rehabilitation done for post hospitalization surgery or trauma. Rehab paid by Medicare has improvement standards based on their hospital discharge codes for benefit coverage.

Jimmo imo seems to be best used for those who
1. have preexisting conditions - MS, ALS, Parkinson’s, post polio syndrome - as they need maintenance or other skilled Out Patient Therapy to “slow or prevent decline”
and
2. getting skilled services in their home.

For NH custodial care residents, due to Jimmo settlement, Medicare will pay for OPT / outpatient therapies. E.g. PTs do gait-training or OTs do hand movement exercises in the rehab sector of a NH. Maybe 2 - 3 times a week. Maintenance not rehab. Its skilled services to prevent further deterioration or preserve current capabilities. Medicare due to Jimmo will pay for specific out-patient therapy care for a resident living in a NH but Medicare will not pay any nursing or room & board custodial cost.

It’s different than Medicare Rehab benefits, which will pay for room & board costs in addition to all rehab, nursing & skilled services based on a patient’s ICD-10 codes. Rehab will be measured & time limited. Should rehab patient reach a plateau, as notated in their rehab chart, or reach max # of days, Medicare will stop rehab coverage.

Jimmo doesn’t come into consideration for rehab; Jimmo comes into consideration if it’s to provide services for prolonged nonrehab care.

If a discharged from rehab patient cannot return to their home or a family members home to live, they can continue to stay in the NH but will move from being a rehab patient paid by health insurance (Medicare and their supplemental) to a custodial care resident. Medicare does not pay custodial costs. Custodial costs are private pay, LTC insurance or they file for LTC Medicaid. But due to Jimmo, Medicare will pay for some out patient services IF it will slow or prevent decline and IF custodial care resident is able to participate. And that’s the rub, as so many custodial residents in a NH aren’t competent enough to follow through on instructions or are physically unable to participate.

Yeah an appeal can be filed. & a redetermination hearing to a failed appeal as well. But the info in their health charts are pretty much updated to Medicare regularly. Sometimes in real time. Info is there and in detail to support why services were stopped. Medicare OPT reimbursement is pretty good, NH therapy staff wont deny providing services if there’s possibility of getting paid.
Often it’s difficult for families to accept that their family member is deteriorating no matter what is attempted. Jimmo settlement, sadly, does not matter if that’s the situation.

This was recently in a Suze Orman newsletter.

‘If you or a loved one is enrolled in Medicare, it’s important to stay on top of developments. Too often, people enroll and then stop paying attention to the plan they are enrolled in, or just accept whatever they are told their coverage will be during each annual renewal period. That can mean paying more or being denied covered care.

You are not going to just accept that, right?

Okay, here are two important issues you need to be aware of:

Appeal any denials of coverage.

If you are enrolled in a Medicare Advantage plan, you likely need to get pre-authorized approval for plenty of big-ticket care costs. What you need to know is that if your insurer says no to a preauthorization request, it’s not likely a hard no.

A study by the non-partisan Kaiser Family Foundation found that when patients appealed an initial denial, the insurer reversed its decision in more than 80% of the cases, and agreed to cover the cost in whole or in part.

Let me make sure that’s clear: When patients were denied coverage (preauthorization was not granted) but then persevered and filed an appeal, insurers in more than 80% of those appeals basically said, “Oh, okay, we’ll cover it.”

It’s hard not to see this as an attempt by insurers to save money, by starting at “No.” In fact, insurers know that most enrollees don’t appeal: In 2022 just 10 percent of people denied coverage filed an appeal.

If you are a child of a parent or loved one enrolled in a Medicare Advantage plan, I want you to be aware of this. If you hear your loved one was denied coverage, please help them file an appeal. There’s a very good chance the insurer will change its mind and pay for the requested service.

The new cap for Part D drug costs may cause higher premiums.

Beginning in January, there is a $2,000 cap on what an enrollee will be required to cover out of pocket for prescription drug costs. This will represent a big savings for enrollees who are prescribed high-cost medications.

That’s great news for enrollees. However, it is expected to cause insurers to increase the monthly premium cost for Part D prescription drug plans, and it could cause insurers to change their rules on what drugs they cover.

That’s why anyone with a Part D plan—whether you currently use it to pay for medications or not—needs to be extra sure to pay attention to their 2025 renewal notice that will soon be arriving (if it hasn’t already).

This is not the year to ignore this notice. You need to make sure you know what your premium will be—insurers will release 2025 rates soon—and if you are currently prescribed medications, double-check that they will continue to be covered by your current plan at an affordable rate. From October 15 to December 7, you can make changes to your Medicare plans, including Part D coverage.

Shopping around for the most cost-effective Part D coverage makes a ton of sense. Just be sure to consider both the monthly premium and any copays for a given drug you currently use. And of course, confirm that the plan does indeed cover the drug. The government’s Medicare Plan Finder will show you plans available in your area. Or if you have a trusted Medicare insurance agent, ask them to help you analyze your options for 2025.”

Understanding Medicare Coverage for Rehab and Home Health Services

Medicare Part A provides coverage of up to 100 days of inpatient rehabilitation in a skilled nursing facility (SNF) per benefit period. However, full coverage is limited to the first 20 days. Starting on day 21, patients are responsible for a daily copayment, which is $200 per day in 2024. After 100 days, Medicare coverage for inpatient rehab ends.

For patients who require ongoing therapy to prevent their condition from deteriorating, Medicare Part B can cover outpatient therapy services, such as physical, occupational and speech therapy. These services are typically provided in an outpatient setting rather than a skilled nursing facility.

However, if a doctor examines the patient and determines that continued therapy is necessary after rehab, they can order home health services, including physical therapy. Home health therapy is covered under Medicare Part A or Part B, depending on the specific circumstances. To qualify, a doctor must certify that the patient is homebound and requires intermittent skilled nursing care or therapy. The patient must also receive care from a Medicare certified home health agency. Medicare will then cover necessary services, including physical therapy, without time limits, as long as the patient remains eligible.

This option allows patients to continue receiving the care they need at home, without having to stay in a facility.

Source: 1-800-Medicare

This is very fascinating and I had absolutely NEVER heard of this.
I wonder what this means in terms of length of time covered. As we all know it seldom exceeds 21 days. I wonder what it has to do with any ability to participate in any therapies.

Very interesting. Thank you for posting this. I hope we will get to hear more.