Medicare Covers Maintenance Therapy in Skilled Nursing: The Jimmo Settlement

The "Improvement Standard" Medicare Was Never Supposed to Use

For decades, skilled nursing facilities and Medicare contractors routinely denied continued coverage when a patient stopped showing measurable improvement in physical or occupational therapy. The logic seemed intuitive: if the patient has plateaued, skilled therapy is no longer "medically necessary." Families across Minnesota heard this from rehab facility staff every day — your parent is no longer making progress, so Medicare coverage is ending.

That logic was wrong, and it has been illegal since 2013.

The Jimmo v. Sebelius settlement, finalized in January 2013, established that Medicare coverage of skilled nursing and therapy services cannot be denied solely because the patient is not expected to improve. Medicare must cover skilled care that is necessary to maintain the patient's current condition or to prevent or slow further decline, as long as the services require the skills of a qualified professional.

This distinction matters enormously for families managing a parent's SNF discharge in Minnesota. A patient with advanced Parkinson's disease who needs skilled therapy to maintain safe swallowing and prevent aspiration pneumonia can qualify for Medicare coverage — even though the disease is progressive and the patient will never "get better." A stroke patient whose therapist is performing range-of-motion exercises to prevent contractures can qualify for skilled coverage when the assessment and execution of that program requires clinical judgment.

What Changed After Jimmo

Before the settlement, Medicare Administrative Contractors (MACs) applied an unofficial "improvement standard" — if the patient's functional measurements stopped improving across therapy sessions, the MAC would deny further coverage. Facilities internalized this standard and proactively discharged patients rather than risk a denial.

The settlement required CMS to issue new guidance clarifying that skilled care is covered when:

• A skilled clinician is needed to assess the patient's condition and design an appropriate maintenance program
• The complexity of the patient's condition requires skilled observation and intervention that a non-professional caregiver cannot safely provide
• The services are reasonable and necessary to maintain function or prevent decline

CMS issued clarifying transmittals and updated the Medicare Benefit Policy Manual to remove improvement-standard language. But compliance has been uneven. A 2018 HHS Office of Inspector General study found that MACs and facilities continued to apply improvement-based denials in practice, despite the settlement. Families who do not know about Jimmo accept these denials without challenging them.

How This Applies to Minnesota SNF Stays

When a skilled nursing facility in Minnesota issues a Notice of Medicare Non-Coverage (NOMNC) stating that therapy services are ending, the facility must deliver that notice at least two calendar days before covered services stop. The family then has until noon on the day before termination to file an expedited appeal with Commence Health (1-888-524-9900), Minnesota's BFCC-QIO.

In your appeal, the Jimmo settlement is the legal foundation for arguing that skilled maintenance therapy should continue. The key phrase to use in your appeal statement: "The patient requires skilled services to maintain current function and prevent decline, consistent with the Jimmo v. Sebelius settlement. Coverage cannot be denied solely because the patient is not expected to improve."

Support that statement with specific clinical details:

• What skilled assessment does the therapist perform at each session that a non-professional cannot replicate?
• What would happen to the patient's function without continued skilled intervention?
• What complications (falls, contractures, aspiration, skin breakdown) is the therapy program designed to prevent?

The independent physician reviewer at Commence Health evaluates the appeal against Medicare's coverage criteria, which now include the Jimmo maintenance standard. If the reviewer agrees the services are skilled and medically necessary, Medicare coverage can continue. If the QIO upholds the termination, services provided after the coverage end date may become the patient's financial responsibility.

Requesting the Detailed Explanation of Non-Coverage

If Medicare denies coverage for skilled services — whether through a NOMNC or a subsequent claims denial — you can request a Detailed Explanation of Non-Coverage (DENC) through the fast-appeal process. After the facility receives notice of the appeal from the BFCC-QIO, it must provide the DENC by the end of that day. The DENC explains the specific reasons and coverage criteria supporting the termination.

Review the DENC carefully. A reference to "plateau," "no further improvement expected," or similar phrasing does not by itself justify ending coverage; under Jimmo, lack of expected improvement alone is not enough when skilled care is otherwise reasonable and necessary. Quote that language in your appeal to Commence Health or in a Medicare reconsideration request.

The Practical Takeaway

Do not accept a rehab discharge at face value when the facility says Medicare coverage is ending because your parent has "plateaued." Ask the treating therapist directly: does my parent still need skilled assessment and intervention to maintain their current level of function? If the answer is yes, Jimmo means lack of improvement alone is not enough to end coverage; use that point in an appeal.

The Minnesota Hospital Discharge Guide includes the complete NOMNC appeal timeline, Commence Health contact scripts, and a framework for building a maintenance-therapy coverage argument grounded in Jimmo — all designed for families who need to act within the tight two-day appeal window.

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