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 CMS Formally Scraps ‘Improvement Standard,’ But Ambiguities Remain

​The Obama administration has formally scrapped the so-called “improvement standard” for care, but the
new rules on Medicare eligibility still leave questions open on such matters as therapy and whether contractors will still be held to the old standard. 
 
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) settled a federal lawsuit that challenged the improvement standard. CMS had been denying some claims for long term care and therapy because the patients couldn’t demonstrate that their conditions would improve. The lawsuit was called Jimmo v. Sebelius
 
Under the settlement, CMS agreed to abandon the improvement standard. The agency published a revised manual earlier this month. In “clarifying” language, the agency now says that the improvement standard never was in place and shan’t be in the future. 
 
It’s a relief for thousands of patients and caregivers who were left to their own devices when trying to obtain basic services just to maintain a quality of life. 
 
That doesn’t mean there may not be conflict in the future, however. Tacked along next to the clarifying improvement standard language, CMS reminds the public that nothing in the Jimmo settlement requires it to widen coverage for patients. 
 
“As such, CMS takes the position that the revised manual material does not represent an expansion of coverage, but rather, provides clarifications that are intended to help ensure that claims are adjudicated accurately and appropriately in accordance with the existing policy,” a memo circulated by the American Health Care Association (AHCA) says.
 
Providers have also raised concerns about the revised manual’s effect on therapists and other contract caregivers.
 
“The new manual language inconsistently describes what a therapist can do versus what a therapy assistant can do related to maintenance programs,” the Dec. 24 AHCA memo says. “CMS indicated that it has not changed the requirements. However, only a ‘qualified therapist’ can establish and perform a therapy maintenance program.”
 
The new manual also used improvement standard language for some contractors, but CMS claims that it has briefed contractors and that no one will be subject to the standard.
 
“There is a fairly extensive expansion of documentation requirements in the new manual language,” the AHCA memo says. 
 
CMS says that the revised manual actually doesn’t specifically expand documentation requirements, but that the agency needs enough paper from Medicare contractors so that it can (in the words of the AHCA memo): 

  • Understand that the provider is meeting the skilled coverage requirement;
  • Know and communicate what the treatment goals are and the progress being made toward achieving them; and
  • Understand that the patient’s needs are complicated, and that the necessary skills are complex.

​Go here for a copy of the CMS memo on Jimmo: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8458.pdf

 

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