Back to Insights and Updates for ProvidersApril 2024

Jimmo Settlement: reminders and provider resources

Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Senior Care Options  |  Tufts Medicare Preferred

The Centers for Medicare and Medicaid Services (CMS) recently issued a memorandum for Medicare Advantage Organizations (MAOs), which provides important clarifying information and valuable educational resources for MAOs such as Point32Health — and our contracted providers — related to the Jimmo v. Sebelis Settlement Agreement (January 2013).

We’re sharing this information with our network as a reminder, to ensure that any providers who serve members of our Harvard Pilgrim and Tufts Health Plan Medicare Advantage plans are aware of the coverage requirements established by the Jimmo Settlement and are providing services in accordance with current Medicare policy.

The Jimmo Settlement clarified that under the Medicare program, skilled nursing and skilled therapy services are covered/appropriate not only when a beneficiary is expected to improve, but when these services are necessary to maintain the patient’s current condition or prevent or slow further deterioration, as long as:

  • the patient requires skilled care for the services to be safely and effectively provided.
  • an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program.

The recent memo from CMS offers links to a number of training and educational materials, which providers are encouraged to review for a better understanding of Medicare policies and coverage guidelines associated with the Jimmo Settlement.

Please keep in mind that this article and the recent CMS memo are not intended to constitute a change in Medicare policies, but rather to serve as a reminder of the clarifications and guidelines originally issued by the Jimmo Settlement in 2013.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Ellen Gustavson, Ryan Francis, Stephen Wong,

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