The Jimmo settlement is a 2013 federal court settlement that ended Medicare’s unwritten improvement standard — the practice of cutting off skilled nursing and therapy coverage because a patient was not getting better. Under Jimmo, coverage turns on whether skilled care is needed, not on whether the patient is expected to improve. Care to maintain function or to slow decline can be covered.
The case was Jimmo v. Sebelius, filed in the U.S. District Court for the District of Vermont on behalf of Medicare beneficiaries with long-term and progressive conditions. The court approved the settlement in January 2013. The Centers for Medicare and Medicaid Services then revised the relevant chapters of the Medicare Benefit Policy Manual and, after further litigation over whether the message had actually reached providers, was ordered to publish a formal corrective statement, which it did in 2017.
What follows is a look at whose interests this settlement serves and who bears its costs, because that framing explains why the policy is correct on paper and still routinely ignored at the bedside. It also gives the concrete appeal steps. This is education, not legal advice or a coverage determination.
In This Article
What Changed, Precisely
Medicare’s statutory coverage rules did not change. Jimmo did not create a new benefit, did not extend any day limit, and did not lower any threshold for admission.
What changed was the standard applied when deciding whether care already covered by the statute qualifies as skilled. Before Jimmo, contractors and providers widely applied a rule of thumb: if the patient has plateaued, coverage stops. After Jimmo, the question is whether the services require the skills of a qualified therapist or nurse to be performed safely and effectively — including where the goal is to maintain the patient’s current condition or to prevent or slow deterioration.
CMS revised manual guidance for three settings: skilled nursing facility care, home health care, and outpatient therapy. As of 2026 that guidance stands, and CMS maintains a dedicated Jimmo page with the corrective statement on its website. The corrective statement is a short document, and printing it is one of the more useful things a family can do.
What did not change is just as important. The three-day qualifying inpatient hospital stay for Part A skilled nursing facility coverage still applies. The 100-day limit per benefit period still applies, with a daily coinsurance for days 21 through 100. Homebound status is still required for home health. Purely custodial care — help with bathing, dressing, meals, supervision — is still excluded from Medicare.
Who Benefits: The Conditions This Was Written For
Jimmo matters most to people whose conditions do not improve by definition. Multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s disease, Alzheimer’s disease and other dementias, the long tail after a serious stroke, spinal cord injury, and advanced heart or lung disease.
Concretely, it supports coverage for things like a physical therapist maintaining range of motion to prevent contractures, a speech-language pathologist managing swallowing safety in a progressive neurological disease, or a skilled nurse managing a complex wound that will not heal but will worsen without care. In each case the patient will not get better. Under Jimmo, that is not the question.
The population also includes people receiving home health who were told they had plateaued and were discharged from the benefit. Home health has no day limit at all, and it is the setting where the improvement standard did the most quiet damage, because a discharge from home health is rarely appealed.
The secondary beneficiaries are families. Every day Medicare covers skilled care is a day the household is not paying privately. That matters enormously in a system where private-pay skilled nursing runs, according to national cost-of-care surveys of the Genworth type, in the range of roughly $300 to $400 per day for a semi-private room as of the mid-2020s, with wide state variation. Confirm current local figures with your Area Agency on Aging.
Who Pays: The Costs The Settlement Moved Around
Medicare pays more. That is the direct fiscal consequence and it is the point of the litigation.
Providers bear documentation cost. Coverage under a maintenance standard requires the clinician to document why the services need a skilled professional. Documentation that once said “no progress, discharge” now has to explain the skilled need. That is real clinician time, and providers who have not retrained staff simply keep discharging, because the old note is faster to write.
Beneficiaries bear the enforcement cost. This is the part nobody warns families about. Jimmo did not create an automatic protection. It created a standard that someone has to invoke. If a facility issues a notice of non-coverage on plateau grounds, the burden of pushing back is on the patient and family, in a compressed timeframe, while the patient is sick.
That asymmetry is the whole practical story of Jimmo, and it is why more than a decade after the settlement the corrective statement is still the most-printed page on the subject. The rule is right; the default is still wrong.
| Party | What Jimmo gives them | What it costs them |
|---|---|---|
| Beneficiary with a progressive condition | Coverage for skilled maintenance care | Must invoke it; short appeal deadlines |
| Family caregiver | Days Medicare pays instead of the household | Time spent appealing while the patient is sick |
| Provider or facility | Reimbursement for continued skilled services | Documentation of skilled need; staff retraining |
| Medicare program | A legally defensible standard | Higher outlays for maintenance therapy |
The Notices, And The Clock On Each
Denials arrive as forms with deadlines. Learn the names.
The Notice of Medicare Non-Coverage is issued when skilled nursing facility, home health or comprehensive outpatient rehabilitation services are ending. It must be delivered at least two days before coverage ends, and it explains the right to an immediate, expedited appeal to the Beneficiary and Family Centered Care Quality Improvement Organization for the region. The expedited appeal window is very short — typically by noon of the day after the notice — and the QIO decision comes back within a couple of days. Do not wait to gather paperwork; call and file, then send the documentation.
The Advance Beneficiary Notice of Non-coverage is used in outpatient settings when a provider believes Medicare will not pay. Signing it does not mean you agree; you can select the option that requires the provider to bill Medicare anyway so that you receive a formal determination you can appeal.
The Medicare Summary Notice, or the Explanation of Benefits from a Medicare Advantage plan, is where a denial that nobody flagged in person eventually appears. Read it. There is a 120-day window from receipt to file a standard redetermination request.
Free help exists and it is genuinely good: the State Health Insurance Assistance Program (SHIP) in your state, the Medicare Rights Center, and, for anyone in a nursing facility, the long-term care ombudsman.
What Jimmo Is Confused With
Medicaid. Jimmo is a Medicare rule. It does not touch Medicaid eligibility, the asset limit, the look-back, or estate recovery. Families in the middle of a spend-down often assume a Jimmo win changes their Medicaid picture. It does not. See how estate recovery works for the Medicaid side of the ledger.
The three-day inpatient rule. Jimmo governs whether care is skilled. The three-day rule governs whether Part A skilled nursing coverage is available at all. A patient can win the Jimmo argument and still be denied because they were in observation status. Read the three-day inpatient rule; it is the more common trap of the two.
Long-term care insurance benefit triggers. A private LTC policy pays on its own contractual trigger, typically inability to perform activities of daily living or severe cognitive impairment. That trigger is unaffected by Jimmo. See how LTC benefit triggers work.
Custodial care. Still excluded from Medicare. Jimmo expanded the definition of skilled maintenance care; it did not make Medicare a long-term care program. This is the misunderstanding most likely to cost a family months of planning time.
The Life Insurance Angle: There Isn’t One, And That Matters
Be plain about this. The Jimmo settlement has no connection whatsoever to whether you should keep, reduce, surrender or sell a life insurance policy. It is a Medicare coverage standard. Nothing about it changes a policy’s value, a carrier’s obligations, or a household’s insurance decisions. Anyone who tells you a Jimmo denial is a reason to sell a policy is selling something.
What it does affect is the bill. And the sequence there matters enormously, because families routinely liquidate assets to pay for care that Medicare should have covered.
The correct order of operations when a therapy or skilled nursing denial arrives is: first, invoke the appeal. It is fast, it is free, and the expedited QIO route resolves in days. Second, call SHIP and, if the patient is in a facility, the long-term care ombudsman. Third, ask the clinician to document the skilled need in the maintenance-standard language the CMS corrective statement uses. Only after those steps have run their course should anyone be selling assets to cover a bill.
If the appeals are exhausted and a genuine private-pay gap remains, then and only then does the question of what to do with an in-force policy become live — and it is a real question, since a policy is often the largest unexamined asset a household owns. Our pages on paying for care without long-term care insurance and when keeping the policy is the right answer cover both directions honestly. For a free, no-obligation review of what a specific policy is worth, send the cover page or call (732) 978-9575.
Frequently Asked Questions
Does Jimmo mean Medicare has to keep paying as long as I need care?
No. Jimmo removed improvement as a condition of coverage, but every other rule still applies. The three-day qualifying hospital stay, the 100-day skilled nursing limit per benefit period, homebound status for home health, and the exclusion of purely custodial care all survive. Jimmo changes the standard for judging skilled care, not the structure of the benefit.
What do I say when a therapist tells me my parent has plateaued?
Ask whether the services still require the skills of a qualified therapist to be performed safely and effectively, including to maintain function or slow decline. That is the Jimmo standard and it is the language the CMS corrective statement uses. Print the statement from the CMS Jimmo page and bring it to the care conference.
How fast do I have to appeal a notice of non-coverage?
Very fast. A Notice of Medicare Non-Coverage must be delivered at least two days before services end, and the expedited appeal to the regional Beneficiary and Family Centered Care Quality Improvement Organization generally must be requested by noon of the day after you receive it. Call and file first, then send documentation. A standard redetermination has a longer 120-day window.
Does Jimmo apply to Medicare Advantage plans?
The coverage standard applies to Medicare Advantage as well, since plans must cover at least what original Medicare covers. The appeal path differs: you use the plan’s own appeal process, with an expedited option, and denials appear on the plan’s explanation of benefits rather than a Medicare Summary Notice. Ask your SHIP counselor to walk you through the plan’s specific steps.
Where can I get free help with a denial?
The State Health Insurance Assistance Program in your state provides free one-on-one Medicare counseling. The Medicare Rights Center operates a national helpline. For anyone living in a nursing facility or assisted living, the long-term care ombudsman program is free and independent. None of these charge, and all three handle improvement-standard denials routinely.
Should a Jimmo denial make me consider selling a life insurance policy?
Not as a first step, and not on its own. Jimmo has no relationship to life insurance. Appeal first, because the expedited route is free and resolves in days. Only if the appeals are exhausted and a real private-pay gap remains does an in-force policy become part of the conversation, and even then keeping it is often the better answer.
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Related Reading
- What Is The Medicare Three Day Inpatient Rule
- What Is An Ltc Benefit Trigger
- What Is Medicaid Estate Recovery
- No Ltc Insurance Pay For Care
- Keeping The Policy Is The Right Answer
- Ltc Insurance Denied
- What Is A Viatical Settlement
- What Is A Life Settlement
Pine Lake Legacy does not purchase life insurance policies and does not provide legal, tax, or investment advice. Information provided is for educational purposes only. Eligibility for any option, including life settlements, is not guaranteed and depends on individual circumstances, policy terms, underwriting, and market conditions. Consult independent legal, tax, or financial professionals before making decisions regarding a life insurance policy.