CurrentHealth NetPolicy N/A

Maintenance Skilled Nursing and Therapy Coverage Criteria

Defines Medicare coverage expectations after the Jimmo settlement for skilled nursing and therapy maintenance services — who is affected includes providers, contractors, and adjudicators handling Medicare skilled nursing facility, home health, and outpatient therapy benefits.

Policy Summary

PayerHealth Net

PolicyMaintenance Skilled Nursing and Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2017

Next Review DateN/A

Key ActionDocument and continually evaluate the beneficiary's need for skilled care and why withholding maintenance services would accelerate decline.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

maintenance allowedMaintenance allowed

continuous evaluationContinuous evaluation

no improvement requirementNo improvement requirement

SNF/HH/OPApplies to settings

Coverage Criteria — Maintenance Skilled Nursing & Therapy

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Maintenance Skilled Nursing and Therapy Coverage Criteria

Covered when ALL of the following are met

Need for skilled care: Beneficiary requires skilled nursing or therapy care such that skilled care is necessary to safely and effectively provide the services (specialized judgment, knowledge, and skills of qualified clinicians).

Provider must continually evaluate the individual's need for skilled care.

Purpose of services: Services are reasonable and necessary to maintain the patient's current condition or to prevent or slow further deterioration.

Applies to maintenance programs delivered by skilled providers per the Jimmo settlement.

Documentation and rationale: Medical record documents why withholding the services would accelerate the beneficiary's natural rate of decline, using evidence-based justification or demonstration that a natural rate of decline has been interrupted when appropriate.

Decisions and justifications should be evidence-based and reflect the provider's clinical judgment and experience.

Other Medicare coverage criteria: All other Medicare coverage requirements for the specific benefit and setting (statutory limits, frequency, setting-specific rules) are met.

The Jimmo settlement affects only the skilled care requirement; other coverage requirements remain unchanged.

Services should be denied as not medically necessary when the beneficiary no longer requires skilled care to safely and effectively provide those services. Denial language must reflect the actual basis for denial (lack of need for skilled care) rather than incorrectly stating that maintenance care is categorically non-covered or that an expectation of improvement was required.

When maintenance services are provided, the medical record must document why withholding the services would accelerate the beneficiary’s natural rate of decline; absence of that documentation or clinical justification supports a determination that continued services are not medically necessary.

Provider Responsibilities, Documentation & Denials

Prior Authorization

Prior Authorization & Coverage Linkage

Prior authorization and coverage are linked to Medicare's reasonable and necessary standards: coverage for skilled nursing and therapy services is contingent on the beneficiary's need for skilled care and that services meet Medicare's reasonable and necessary criteria. Providers should obtain any required prior authorization when applicable and ensure documentation demonstrates that skilled care is required to safely and effectively provide the services.

Prior authorization when required by the payer must be obtained before services are rendered.
Coverage depends on documented need for skilled care and meeting Medicare "reasonable and necessary" criteria.

Denial Risk

Appropriate Denial Language

Denial language must accurately reflect the reason for noncoverage. Do not state that maintenance care is categorically non-covered or that coverage requires an expectation of improvement. If denying a claim, specify that the services are not covered because the beneficiary no longer meets the requirement for skilled care (if that is the factual basis) and cite the applicable coverage standard.

Avoid shorthand denials such as "maintenance therapy not covered" or "no potential for improvement."
Use precise language explaining that denial is based on lack of demonstrated need for skilled care, and reference the Medicare standard.

Documentation Required

Documentation to Support Maintenance Therapy

When maintenance therapy is provided, the medical record must document why withholding the services would accelerate the beneficiary's natural rate of decline. Documentation should be evidence-based and reflect the provider's clinical judgment, experience, or other supporting evidence showing the expected natural history and how services alter that trajectory.

Document the clinical rationale for maintenance therapy and why services are necessary to prevent or slow deterioration.
Where applicable, include objective measures or historical rate-of-decline information that maintenance services interrupt.

Documentation Required

Ongoing Evaluation & Documentation

Providers must continually evaluate and document the ongoing need for skilled care. Clinical determinations about continued coverage should be made on an ongoing basis and reflected in the medical record, demonstrating that skilled services remain necessary to maintain the patient's condition or prevent further decline.

Perform and record periodic reassessments of the beneficiary's need for skilled care.
Document rationale for continuation or discontinuation of skilled services based on current clinical status.

Note

Provider Action: Response to Claim Reviews

Provider/billing action: ensure appeals or reviews follow settlement-specified processes when reviewing past claims, and respond to re-reviews or sampled appeals with complete documentation of skilled-care need and contemporaneous clinical justification.

Retain documentation to support potential re-review or appeal (sections of Settlement Agreement may apply).
If contacted for claim re-review, provide evidence showing skilled care necessity and maintenance rationale.

Key Definitions

inv-10: Maintenance services 6 definition and scope

TermMaintenance services

DefinitionPrograms intended to maintain the patient’s current condition or to prevent or slow further deterioration, provided the beneficiary requires skilled care for the services to be safely and effectively performed.

ScopeApplies to skilled nursing facility, home health, and outpatient therapy benefits when all other Medicare coverage criteria are met.

Documentation requirementProvider must document that skilled care is required for safe and effective performance of the maintenance program.

Coverage implicationMaintenance programs are covered when reasonable and necessary and the beneficiary needs skilled care to perform the program safely and effectively.

inv-11: Skilled care 6 definition describing specialized judgment, knowledge, and skills

TermSkilled care

DefinitionThe specialized judgment, knowledge, and skills of qualified clinicians (e.g., therapists or nurses) necessary for the safe and effective performance of a maintenance program.

Functional roleDetermines whether services required to maintain or prevent/slow deterioration can be performed safely and effectively by non-skilled personnel or require skilled clinicians.

Ongoing dutyProvider must continually evaluate the individual’s need for skilled care as part of medical necessity determinations.

Policy effectCoverage under Jimmo depends on need for skilled care, not on expectation of improvement; if skilled care is required, maintenance services may be covered when other criteria are met.

Day Limits and Related Billing Notes

inv-15: SNF 6 day limits (billing/coverage related)

SNF Part A 100-day limitThe Jimmo settlement does not change the 100-day Part A SNF benefit limit; other statutory limits remain unchanged.

‘Daily basis’ therapy frequencyThe SNF ‘daily basis’ requirement (therapy on at least 5 of 7 days) and frequency rules remain unchanged by the settlement.

Billing/coverage linkageCoverage for SNF therapy is contingent on meeting Medicare reasonable and necessary criteria, including that skilled care is required for safe and effective provision of maintenance services.

Provider obligationProviders and contractors must continue to apply existing setting-specific rules (billing and coverage) in addition to Jimmo’s skilled-care standard.

Most actionableThe settlement concerns only the skilled-care requirement; all other SNF day limits and billing rules (including the 100-day Part A limit and ‘daily basis’ therapy rules) remain unchanged.

OpenPayer

Maintenance Skilled Nursing and Therapy Coverage Criteria

Coverage Criteria — Maintenance Skilled Nursing & Therapy

Provider Responsibilities, Documentation & Denials

Key Definitions

Admission Criteria for SNF, Home Health & Outpatient Therapy

Criteria for Continued Stay / Ongoing Coverage

Discharge Criteria

Day Limits and Related Billing Notes

Background and Legal Context