Jimmo v. Sebelius

Medicare contractors had been applying an unwritten "Improvement Standard" — denying skilled nursing, home health, and outpatient therapy coverage whenever a patient wasn't likely to get better. The settlement made CMS state plainly, in its own manuals, that this was never the real rule.ruleCMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)

Coverage for skilled care turns on whether the patient needs skilled nursing or therapy — not on whether that care is expected to improve their condition. Skilled care to maintain a current condition, or to slow or prevent decline, can be covered on exactly the same terms as care aimed at improvement.ruleCMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)

The settlement required CMS to revise its own Benefit Policy Manual chapters for SNF, home health, and outpatient therapy services to state the real standard explicitly, and to run a nationwide education campaign so contractors, plans, and providers stopped applying the improvement standard informally, even after the manual language changed.

If a skilled nursing facility or home health denial says (in substance) that your parent "isn't improving" or has "plateaued," that is not, by itself, a valid reason to deny skilled care. The rule asks whether skilled care is still needed — to maintain function or slow decline counts.

A physician's letter that explains why skilled care is needed to maintain the patient's current condition — not just to improve it — directly answers this standard, and is exactly the kind of fact this decision made explicitly relevant.

This settlement is now over a decade old, but the underlying confusion it addressed hasn't fully disappeared — plans, facilities, and even treating providers sometimes still describe coverage in terms of improvement out of old habit, not because the current rule requires it. Naming Jimmo directly in an appeal is a fast way to correct that framing.

The SNF and home-health letter templates state the maintenance/slow-decline standard directly, rather than only describing coverage in terms of improvement — so a letter never accidentally concedes a standard the rule doesn't actually require.