Maintenance Therapy and the Jimmo Standard

There is a persistent belief in home health that a patient who is not improving cannot be covered. It is wrong, it has been wrong for over a decade, and it causes patients to be discharged from care they are entitled to.

What the standard says

The Jimmo v. Sebelius settlement, and the CMS manual clarifications that followed it, confirmed that Medicare coverage of skilled nursing and therapy does not turn on whether the patient improves.

Coverage depends on whether the skills of a clinician are required to deliver the care safely and effectively — not on the patient's potential for improvement.

Skilled care may be covered to:

Improve function
Maintain the patient's current condition
Prevent or slow further decline

This is sometimes called the "improvement standard myth", and CMS has published educational material specifically to correct it.

When maintenance therapy is skilled

It is not enough that the patient is not improving. The test is whether a therapist's skill is genuinely needed. It usually is when:

The programme is complex enough that it requires a therapist to deliver or supervise safely
The patient's condition is such that an unskilled person could not do it safely — because of instability, cognitive impairment, complex precautions, or fragility
The programme needs periodic reassessment and modification by a therapist to remain safe and effective
There are specific risks that a therapist is managing — contracture, skin breakdown, aspiration, falls

It is not skilled when a family member or the patient could carry out the same programme safely with no clinical judgment involved. Repetition alone is not skill.

Where it applies

Typically progressive or stable-but-fragile conditions:

Parkinson's disease, multiple sclerosis, ALS
Advanced dementia with mobility or swallowing risk
Chronic neurological injury with contracture or spasticity risk
Severe COPD or heart failure where the ceiling has been reached
Any patient whose realistic best outcome is holding the line

Documenting it so it holds

This is where maintenance cases are lost, and it is entirely avoidable.

Say plainly that it is a maintenance plan

Do not write a rehabilitation plan with goals nobody expects to meet. Reviewers read that as a failed episode, not a maintenance one.

Plan is maintenance-focused. Patient has reached maximal rehabilitation potential; the goal is preservation of current transfer status and prevention of contracture, not further gains.

Write maintenance goals as measurable

They still need to be measurable — see Writing Measurable Goals.

Patient will maintain sit-to-stand transfer with contact-guard assist, 4 of 5 attempts, through the certification period, with no falls.

Patient will maintain right elbow passive range of motion at or above 15–110 degrees, with no increase in contracture, through the certification period.

State why a therapist is required

The most important sentence on the page. Be specific:

Programme requires a therapist due to fluctuating rigidity and freezing episodes, which require real-time modification of cueing strategy and assistance level. Spouse has been trained in the positioning programme but is unable to judge when the patient's tone makes passive stretch unsafe.

Show the reassessment

Maintenance does not mean unchanging. Each visit should show assessment, judgment, and modification — see Home Exercise Programs for what that looks like written down.

Document what is being prevented

Name the decline you are holding off, and the evidence that you are:

Without the programme, patient is at high risk of hip and knee flexion contracture, which would eliminate standing transfers and require a hoist. Range has been maintained unchanged over eight weeks.

"No change" is a successful outcome here, and should be framed as one.

What it does not mean

Maintenance coverage is not indefinite therapy by default:

The skilled requirement still has to be met, at every visit
The patient must still be homebound — see Homebound Status
The care must still be intermittent
When a caregiver can be trained to take it over safely, train them and discharge
When the programme no longer requires a therapist's judgment, it is no longer skilled

The honest question at every recertification is the same one as for any other patient: does this still require a clinician? See Recertification.

If someone tells you a patient must improve to stay on service

They are describing a standard that does not exist. Raise it with your Field Supervisor and point to the CMS material. Patients have been discharged from care they qualified for because nobody in the room knew this.

Reference

Jimmo v. Sebelius settlement and the subsequent CMS Medicare Benefit Policy Manual revisions; CMS has published a dedicated clarification of the "improvement standard" myth. Confirm current manual language with your QA team before relying on specific wording in an appeal.