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CMS clarifies coverage requirements for skilled nursing, therapy services

December 12, 2013

The Centers for Medicare & Medicaid Services has revised its Medicare program manuals to clarify that skilled care or skilled therapies services may be covered in situations where no improvement in condition is expected, but the services are needed to prevent or slow a decline in condition. Required under a January settlement between the Department of Health and Human Services and plaintiffs in a lawsuit alleging that Medicare contractors were inappropriately applying an “improvement standard” in making claims determinations for Medicare coverage involving skilled care, the manual updates disclaim an improvement standard and clarify that coverage is based on whether an individualized assessment of the beneficiary’s medical condition indicates that skilled care is required, as well as the reasonableness and necessity of the treatment, care or services in question.