Who Is Glenda Jimmo and Why Should My Team Know About Her?
You have known hundreds of patients just like Glenda Jimmo. Elderly, diabetic, multiple comorbidities. But this Vermont senior and mother of four will be forever known in history as the one who fought against the federal government, at the age of 76, and won. Ms. Jimmo was the lead plaintiff in a 2011 class-action lawsuit seeking to broaden Medicare’s criteria for covering physical therapy and other care delivered by skilled professionals. On January 24, 2013, the US District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care. The landmark settlement, known as the Jimmo Agreement, was heralded as a victory for Medicare beneficiaries receiving treatment for chronic conditions and disabilities.
But wait, don’t patients have to show progress in order to qualify for skilled therapy? Many of us in the rehab world had it ingrained in our brains that patients need to demonstrate progress in order to qualify for Medicare coverage. However, per the CMS update following the Jimmo Agreement:
While an expectation of improvement would be a reasonable criterion to consider when evaluating, for example, a claim in which the goal of treatment is restoring a prior capability, Medicare policy has long recognized that there may also be specific instances where no improvement is expected but skilled care is, nevertheless, required in order to prevent or slow deterioration and maintain a beneficiary at the maximum practicable level of function. For example, in the regulations at 42 CFR 409.32(c), the level of care criteria for SNF coverage specify that the “. . . restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”
- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf
This is what we now refer to as “maintenance therapy”.
While Medicare denies its statutes and regulations have ever supported the imposition of an “Improvement Standard” in determining whether skilled care is required to prevent or slow deterioration in a patient’s condition, they nonetheless agreed to update program manuals used by Medicare contractors who were unclear on that point. They clarified that coverage for skilled services depends not on the beneficiary’s restoration potential, but rather coverage depends on whether skilled care is required.
Following the updates, CMS began an educational campaign for contractors, adjudicators, and providers and suppliers. Medicare was later criticized for not adequately carrying out the promised educational campaign to notify stakeholders and many long-term care administrators and therapists are still not aware today of the coverage availability and requirements.
Meanwhile, Ms. Jimmo is alive and well in Vermont, and last I heard, still receiving skilled therapy at home to maintain her condition. Thank you, Ms. Jimmo, for paving the way for American seniors to get the skilled care they need and deserve.
Curious to read more about Ms. Jimmo and the Settlement’s impact on skilled services? These are helpful sources for additional information regarding the Jimmo Settlement and patient care:
Jimmo v. Sebelius Settlement: The myth of the Medicare improvement standard. A helpful Q&A by Nancy J. Beckley, MS, MBA, CHC: http://www.ppsimpact.org/jimmo-v-sebelius-settlement-2/?print=print
Articles covering the Jimmo Settlement by Susan Jaffee, a Washington, D.C. reporter who covers health policy and aging issues: http://susanjaffe.org/tag/jimmo-settlement/
Previously mentioned CMS Jimmo Settlement Fact Sheet: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf
Healthcare reporter, Andrew Stein, directly interviewed Ms. Jimmo for his 2012 article, Lincoln woman was the lead plaintiff in national class action lawsuit against Medicare: https://vtdigger.org/2012/10/26/lincoln-woman-lead-plaintiff-in-national-class-action-lawsuit-against-medicare/
Seagrove Rehab Partners can not only educate your team on which services are covered, but we provide chart audits to assess documentation and offer ongoing oversight to ensure your residents get the care they need and that services are reimbursed. Proper documentation is essential to support the need for skilled therapy intervention, as it establishes why the clinical and critical thinking of a therapist is required, so that patients like Ms. Jimmo can benefit from covered treatments to maintain their current level of function and quality of life.
Written by: Elizabeth Johnson, PT, CDP, RAC-CT, Regional Vice President, Seagrove Rehab Partners
