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Judge: CMS fails to educate on maintenance therapy coverage changes

August 24, 2016
by Pamela Tabar, Editor-in-Chief
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The Centers for Medicare and Medicaid Services (CMS) hasn’t done a very good job educating beneficiaries, providers and claims auditors on how “maintenance therapies” are covered, says a U.S. District Court judge. The court has given CMS a 45-day window to implement an improved educational plan, notes Bloomberg BNA.

Since the 2013 settlement in Jimmo v. Sebelius, the Centers for Medicare and Medicaid Services (CMS) has been required to cover therapies that help maintain a chronic condition or prevent a patient from declining, including home health, skilled nursing, outpatient physical therapy and other skilled-care therapy services. Prior to Jimmo, CMS would cover therapies only if they were expected to help the patient’s condition improve.

Prime examples within senior care include skilled-care maintenance therapies for those who have experienced a stroke and those with Parkinson’s or Alzheimer’s disease. Although the afflicted person may “get better,” such therapies can still help maintain quality of life, retain the ability to walk, maintain speech abilities and other benefits.

CMS produced online fact sheets on the coverage changes in early 2013, but three years later, many physicians—and even insurance adjusters and claims auditors—are still unaware of the changes and are erroneously denying coverage for valid services. Last week, a federal court in the District of Vermont found that CMS has only partially succeeded in its orders to fulfill the educational terms of the Jimmo settlement, and has ordered the agency to implement corrective actions within the next 2 months.

Read the U.S. District Court decision here.