If you or a loved one in Georgia has a chronic neurological, musculoskeletal, or progressive condition, including multiple sclerosis, Parkinson's disease, ALS, advanced dementia, stroke residuals, or spinal cord injury, and a clinician told you Medicare would not cover therapy "because you're not getting better," what you heard was the long-discredited improvement standard that the Jimmo Settlement rejected over thirteen years ago.

The case is Jimmo v. Sebelius. The settlement was approved by the U.S. District Court for the District of Vermont. In 2017, the same court ordered additional corrective action after the Center for Medicare Advocacy and Vermont Legal Aid demonstrated that contractors, providers, and CMS had still not fully internalized what Jimmo required.

The Jimmo principle is simple. Medicare covers skilled maintenance therapy and skilled maintenance nursing services when the skill of a qualified professional is required to safely and effectively maintain the patient's condition, prevent deterioration, or slow decline, even if no improvement is expected. Improvement potential is not the test. The test is whether skilled care is required.

This guide explains where Jimmo came from, what the settlement actually requires, how it has been implemented through CMS manual revisions, how Palmetto GBA, Georgia's Medicare Administrative Contractor, applies it in coverage decisions, how documentation should be framed to meet the standard, how to appeal an improperly denied claim, and how Jimmo applies across outpatient physical therapy, occupational therapy, speech-language pathology, home health, skilled nursing facility (SNF) Part A care, and inpatient rehabilitation facility (IRF) services in Georgia.

This is policy-translator territory. The law is decided. The settlement is in force. The manual revisions are published. The question is whether everyone in the system, including contractors, providers, intake teams, and beneficiary representatives, applies the rule the way the court ordered it applied. In Georgia, where outpatient therapy networks, hospital-based rehab, large home health agencies, and the SNF sector all process maintenance-level care daily, knowing Jimmo is not optional.

The Jimmo case: what was actually decided

Filing

  • Filed in the U.S. District Court for the District of Vermont
  • Class action on behalf of Medicare beneficiaries
  • Named plaintiff: Glenda Jimmo, a Vermont Medicare beneficiary who was legally blind, a lower-limb amputee, with diabetes-related complications
  • Plaintiffs' counsel: Center for Medicare Advocacy (Mansfield, CT) and Vermont Legal Aid
  • Defendant: HHS Secretary

Theory

Plaintiffs alleged that CMS, MACs, contractors, and the broader Medicare claims processing system had been applying an unwritten improvement standard, requiring Medicare beneficiaries to demonstrate improvement potential as a precondition for skilled care coverage. They contended this practice was inconsistent with the Social Security Act and CMS's own regulations, which articulate a "reasonable and necessary" standard that turns on whether skilled care is required, not whether improvement is achievable.

The improvement standard had been informally applied for decades across:

  • Outpatient PT, OT, SLP
  • Home health
  • SNF Part A skilled care
  • Inpatient rehab

Beneficiaries with chronic, stable, or progressive conditions were repeatedly denied coverage with rationales like "patient has plateaued," "no further progress expected," and "maintenance only," language CMS regulations did not actually support.

Settlement

The U.S. District Court for the District of Vermont approved a settlement. Core terms:

  1. CMS must clarify that Medicare coverage of skilled care does not depend on improvement potential
  2. CMS must revise the Medicare Benefit Policy Manual, including the Home Health, SNF, and Outpatient Therapy chapters
  3. CMS must revise the Medicare Claims Processing Manual as needed
  4. CMS must conduct an educational campaign for contractors, providers, beneficiaries, and ALJs to ensure correct application
  5. CMS must implement a re-review process for certain denied claims
  6. CMS must monitor compliance

The 2017 corrective action order

By 2016-2017, plaintiffs returned to court demonstrating continued non-compliance. Contractors and providers were still applying improvement-standard language. The court ordered additional corrective action, including:

  • A renewed educational campaign
  • Specific CMS website content clarifying the Jimmo standard
  • Provider-facing materials
  • Additional contractor training

The 2017 order acknowledged that CMS's initial post-settlement educational efforts had been inadequate.

CMS Jimmo Web Page

CMS maintains a dedicated Jimmo Settlement Agreement web page summarizing the settlement and pointing to relevant manual sections.

The Social Security Act and reasonable and necessary coverage

The foundation. Medicare pays for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Note: the statute does not require improvement. "Reasonable and necessary" is the operative phrase. Jimmo simply enforced the statutory standard against the improperly grafted improvement standard.

Skilled vs non-skilled care

The actual coverage test for Medicare skilled care benefits:

Skilled care is care that requires the skill of a qualified professional (registered nurse, licensed therapist, etc.) to be safely and effectively provided. Includes:

  • Assessment and evaluation requiring clinical judgment
  • Treatment requiring professional skill
  • Teaching/training requiring professional skill
  • Observation and monitoring requiring professional skill
  • Management of complex care plans

Non-skilled care is care that a non-licensed person (with appropriate training) could provide safely. Often called custodial or personal care.

Jimmo's point: the line between skilled and non-skilled is about complexity and risk, not about whether improvement is anticipated. Skilled care to maintain function, prevent deterioration, or slow decline is covered when the skill is required.

The maintenance therapy concept

Skilled maintenance therapy includes:

  • Skilled exercise program to maintain function in progressive disease
  • Skilled gait training to prevent falls
  • Skilled adjustment of compensatory techniques as disease progresses
  • Skilled swallowing therapy in progressive neurological disease to prevent aspiration
  • Skilled positioning and transfer training to prevent skin breakdown
  • Skilled caregiver training as condition evolves

When delivered by a qualified professional and required for safety and effectiveness, this care is covered.

How Jimmo applies across Medicare benefits

Outpatient therapy (Part B)

  • PT, OT, SLP under outpatient benefit
  • Plan of care signed by physician/NPP
  • Skilled maintenance therapy is covered when skill is required
  • Documentation must reflect skilled need, maintenance/prevention/slow-decline goal
  • No improvement requirement
  • Therapy cap repealed

Home health (Parts A/B)

  • Homebound status plus skilled need plus plan of care plus physician/NPP face-to-face encounter
  • Skilled nursing or skilled therapy must be needed
  • Maintenance care covered when skilled need exists
  • Common Jimmo applications: progressive neurological disease, advanced wound care, complex medication management

SNF Part A

  • After a qualifying hospital stay
  • Skilled nursing or skilled therapy "daily basis" requirement
  • Maintenance therapy/nursing covered when skilled

Inpatient rehabilitation facility (IRF)

  • Intensive rehab setting
  • More improvement-oriented in admission criteria
  • Jimmo still applies to ongoing maintenance components

Hospice: separate framework

Hospice care is governed by separate benefit rules. Jimmo does not apply to hospice election determinations but may interact with non-hospice care decisions for hospice patients.

Documentation that meets Jimmo

The clinical record should, at minimum, articulate:

  1. The patient's underlying condition and its trajectory (stable, progressive, post-acute plateau)
  2. The specific skilled service being provided (e.g., "skilled adjustment of gait pattern to incorporate cane for safety as MS-related foot drop worsens")
  3. The skilled need: why this requires a licensed professional
  4. The goal: maintenance, prevention of deterioration, slowing decline
  5. The risk if skilled care is withdrawn (e.g., falls, aspiration, skin breakdown, contracture)
  6. The plan of care with measurable maintenance goals (e.g., "maintain transfers with min assist," "maintain swallow safety with chin tuck and modified diet")
  7. Progress notes documenting ongoing skilled need
  8. Reassessment at appropriate intervals

Notes that say "patient plateaued, discharge from therapy" without articulating whether skilled need remains are exactly the kind of documentation that misapplies Jimmo.

Palmetto GBA implementation in Georgia

Palmetto GBA, Georgia's Medicare Administrative Contractor, processes Part A and Part B claims for Georgia. Palmetto:

  • Must apply Jimmo standards in coverage decisions
  • Local Coverage Determinations (LCDs) for outpatient therapy must reflect Jimmo
  • Documentation guidance for therapy LCDs must permit skilled maintenance care
  • Contractor education has been ongoing since the settlement and intensified after the 2017 corrective action

Georgia provider compliance

Outpatient therapy

Major Georgia outpatient therapy networks subject to Jimmo:

  • Emory Rehabilitation
  • Wellstar Rehabilitation
  • Piedmont Rehabilitation
  • BenchMark Physical Therapy (large independent network)
  • Drayer Physical Therapy
  • Athletico Physical Therapy
  • Children's Healthcare of Atlanta (for pediatric Medicare)
  • Various hospital-based outpatient clinics across the state

Each must document maintenance therapy in line with Jimmo. Therapists should not discharge patients with chronic conditions based on improvement plateau if skilled need continues.

Home health

Major Georgia HHAs:

  • Encompass Health
  • Amedisys
  • BAYADA
  • AccentCare
  • LHC Group
  • CenterWell
  • Smaller independent agencies

Skilled maintenance therapy and skilled maintenance nursing in home health are core Jimmo applications. The face-to-face encounter and recertification documentation should articulate skilled need beyond improvement framing.

Skilled nursing facilities

Georgia SNFs across major chains (Pruitt Health, Signature Healthcare, Life Care Centers, others) and independents must apply Jimmo to Part A skilled care determinations.

Inpatient rehab

IRF settings (Shepherd Center for spinal cord and brain injury; Emory Rehab Hospital; Wellstar Rehab Hospital, etc.) primarily focus on intensive rehab but maintenance considerations enter for some patients.

Conditions where Jimmo is most consequential

Multiple sclerosis

Progressive, fluctuating. Skilled PT/OT/SLP and skilled nursing often required to maintain function, prevent falls, manage spasticity, swallow safety, bowel/bladder care.

Parkinson's disease

Progressive neurodegeneration. Skilled gait training, LSVT BIG/LOUD, swallow management, falls prevention.

ALS (amyotrophic lateral sclerosis)

Rapidly progressive. Skilled PT/OT/SLP to maintain function, prevent contracture, manage swallow/respiratory complications, caregiver training.

Post-stroke

After initial recovery plateau, ongoing skilled therapy may be required to maintain function, prevent deterioration, manage spasticity, retrain skills as compensation evolves.

Spinal cord injury

Skilled maintenance care for transfers, skin integrity, bowel/bladder, equipment use as life circumstances evolve.

Advanced dementia

Skilled OT for safety strategies; skilled SLP for swallow management; skilled nursing for complex care planning. Jimmo-relevant care often misclassified as custodial.

Advanced osteoarthritis / chronic musculoskeletal

Skilled PT for joint protection, exercise progression, function maintenance.

Other chronic conditions

COPD pulmonary rehab maintenance, advanced cardiac conditions, complex wound care, chronic neurological conditions of all kinds.

Worked examples

Example 1: Fulton County, 70, MS, outpatient PT under Jimmo

Patient: 70-year-old Fulton County resident with secondary progressive multiple sclerosis, increasing spasticity, declining balance, history of one fall in past 6 months. Setting: Emory Rehabilitation outpatient. Care: Skilled PT 2x/week for gait training with quad cane, fall prevention, spasticity management techniques, caregiver training in safe transfers. Documentation: Therapist documents declining gait pattern, specific skilled interventions, maintenance/prevention goals (prevent further falls, maintain household ambulation with cane), risk if skilled care withdrawn (falls, fracture, institutionalization). Coverage under Jimmo: Covered. Skilled PT is required to safely maintain ambulation and prevent deterioration. The fact that MS will continue to progress and the patient will not "improve" does not defeat coverage. If denied citing plateau: Appeal citing Jimmo, the Medicare Benefit Policy Manual outpatient therapy maintenance provisions, and the documentation.

Example 2: DeKalb County, 75, Parkinson's, home health under Jimmo

Patient: 75-year-old DeKalb County resident with moderate Parkinson's, freezing of gait, dysphagia for thin liquids. Setting: Encompass Health home health agency. Care: Skilled PT for gait training including cueing strategies; skilled SLP for swallow safety techniques and diet modification training; skilled OT for ADL adaptations; episodic skilled nursing as needed. Documentation: Homebound (taxing effort to leave home), skilled need for each discipline, face-to-face encounter completed by physician, plan of care signed. Coverage under Jimmo: Covered as long as skilled need continues. PT and SLP maintenance for progressive Parkinson's is exactly the kind of care Jimmo protected. Recertification: Every 60 days with updated documentation of continued skilled need.

Example 3: Cobb County, 68, post-stroke, outpatient SLP under Jimmo

Patient: 68-year-old Cobb County resident, 9 months post-left MCA stroke, expressive aphasia, plateau in recovery, ongoing word-finding and functional communication difficulties. Setting: Wellstar outpatient. Care: Skilled SLP 1x/week for functional communication strategies, AAC (augmentative and alternative communication) device training, ongoing maintenance to prevent regression. Documentation: Stroke history, current communication function, specific skilled SLP interventions, maintenance and slow-decline-prevention goals, risk of regression if therapy discontinued. Coverage under Jimmo: Covered when skilled SLP is required for maintenance/prevention. Stroke plateau does not defeat coverage.

Example 4: Worth County, 72, ALS, maintenance care under Jimmo

Patient: 72-year-old Worth County (rural southwest Georgia) resident with bulbar-onset ALS, progressive dysphagia, declining respiratory function, mobility limitations. Setting: Phoebe Putney home health. Care: Skilled SLP for swallow safety and diet modification; skilled PT for mobility maintenance and contracture prevention; skilled nursing for symptom management; skilled OT for ADL adaptations; caregiver training intensifying as needs evolve. Documentation: Rapidly progressive disease, intensifying skilled need, maintenance and slow-decline goals, risk of aspiration/skin breakdown/contracture if skilled care withdrawn. Coverage under Jimmo: Covered throughout the course of disease as long as skilled need exists. ALS is a paradigm Jimmo condition.

Example 5: Bibb County, 80, SNF Part A, skilled maintenance under Jimmo

Patient: 80-year-old Bibb County resident, hospitalized for sepsis and recovered; admitted to SNF for ongoing skilled needs related to complex wound care, IV antibiotic completion, and rehabilitation in setting of advanced dementia. Setting: Atrium Health Navicent-affiliated SNF. Care: Skilled nursing for wound care and IV management; skilled PT/OT for functional maintenance. Documentation: Daily skilled need, plan of care, transitions, expected duration. Coverage under Jimmo: Covered for SNF Part A days as long as skilled need (daily basis) continues, subject to standard benefit period limits. Dementia-related plateau does not defeat skilled wound care/IV/maintenance need.

Example 6: Hall County, 67, outpatient therapy denial, appeal citing Jimmo

Patient: 67-year-old Hall County resident with chronic low back pain and degenerative joint disease; receiving outpatient PT at Northeast Georgia Health System affiliate; denial issued citing "plateau" and "no progress." Appeal strategy:

  1. Redetermination to Palmetto GBA citing Jimmo, the Medicare Benefit Policy Manual outpatient therapy maintenance provisions, and documentation establishing skilled need and maintenance goals
  2. QIC reconsideration if redetermination denied: cite Jimmo, the 2017 corrective action, and request specific reasoning on improvement-standard rejection
  3. ALJ hearing with full record; ALJs have been specifically trained on Jimmo
  4. Medicare Appeals Council if needed
  5. Federal court as final option Resources: Center for Medicare Advocacy self-help packet on the improvement standard; Atlanta Legal Aid; GA Legal Services; Medicare Rights Center.

Best practices for Georgia providers

  1. Eliminate improvement-standard language from intake, evaluation templates, and progress notes
  2. Document skilled need explicitly: what skill, why this professional, what risk if withdrawn
  3. Articulate maintenance/prevention goals in measurable terms
  4. Train all clinical staff on Jimmo, including therapists, nurses, social workers, and intake teams
  5. Use the Center for Medicare Advocacy guidance for documentation templates
  6. Apply Jimmo equally across diagnoses: do not reserve it for select cases
  7. Coordinate across disciplines: PT/OT/SLP/nursing maintenance need is often complementary
  8. Continue recertification with updated documentation when need continues
  9. Issue ABN appropriately: only when service genuinely lies outside Medicare coverage, not as a default for maintenance care
  10. Educate beneficiaries on Jimmo so they can advocate
  11. Engage Palmetto GBA when LCD interpretation seems inconsistent with Jimmo
  12. Maintain Jimmo training records for compliance
  13. Audit denied claims to identify improvement-standard misapplication
  14. Support patient appeals with documentation and clinical letters
  1. "Patient plateaued, discharging": improper if skilled need remains
  2. "No improvement potential" as a denial rationale: facially invalid under Jimmo
  3. "Maintenance only" label used to exclude coverage: incorrect; maintenance care is covered when skilled
  4. Conflating skilled vs non-skilled with improvement vs non-improvement: these are different concepts
  5. Therapy caps historically created confusion; caps were repealed but Jimmo principles continue to govern the substantive coverage standard
  6. Home health face-to-face documentation not articulating skilled maintenance need
  7. SNF Part A denials citing lack of rehabilitation potential
  8. MA plan denials applying an improvement standard contrary to Jimmo
  9. Custodial care misclassification: care that requires skill is not custodial
  10. Documentation training gaps in provider organizations
  11. Contractor education gaps despite the 2017 corrective action
  12. Provider reluctance to bill maintenance therapy out of fear of audit
  13. Family confusion when told "Medicare won't cover this"
  14. Coordination with hospice election: non-hospice Medicare benefits continue for unrelated conditions

Frequently Asked Questions

Jimmo v. Sebelius was a nationwide class action that clarified Medicare covers skilled maintenance therapy and nursing without requiring improvement potential. The settlement was approved by the U.S. District Court for the District of Vermont. It required CMS to revise Medicare manuals and conduct an educational campaign for contractors, providers, and ALJs.

Yes. Jimmo is a nationwide settlement. Palmetto GBA, Georgia's Medicare Administrative Contractor, must apply Jimmo standards in all Part A and Part B coverage decisions. All Georgia outpatient therapy networks, home health agencies, SNFs, and IRFs are subject to the settlement.

Skilled care is covered when the skill of a qualified professional is required to safely and effectively provide the care, including for maintenance, prevention of deterioration, or slowing decline. Improvement is not required. The operative test is whether skilled care is needed.

File an appeal. In your redetermination request to Palmetto GBA, cite the Jimmo settlement, the relevant Medicare Benefit Policy Manual maintenance therapy provisions, and your documentation establishing skilled maintenance need. Contact GeorgiaCares SHIP at 1-866-552-4464 for free counseling, or the Center for Medicare Advocacy for self-help resources.

Jimmo applies to outpatient therapy (PT/OT/SLP), home health, SNF Part A, and inpatient rehab, as well as skilled nursing across those settings. Medicare Advantage plans are also required to follow Jimmo and cannot impose an improvement standard.

Get help with Jimmo and Medicare coverage in Georgia

  • Medicare: 1-800-MEDICARE (1-800-633-4227); medicare.gov
  • Palmetto GBA (MAC for GA): palmettogba.com
  • GeorgiaCares SHIP: 1-866-552-4464; georgiacares.org
  • Center for Medicare Advocacy: medicareadvocacy.org (Jimmo plaintiffs' counsel, comprehensive resources)
  • Vermont Legal Aid: co-counsel in Jimmo
  • Medicare Rights Center: 1-800-333-4114; medicarerights.org
  • Atlanta Legal Aid: 404-377-0701; atlantalegalaid.org
  • Georgia Legal Services Program: 1-800-498-9469; glsp.org
  • 211 Georgia: dial 211
  • Eldercare Locator: 1-800-677-1116; eldercare.acl.gov
  • Georgia Department of Public Health: 404-657-2700; dph.georgia.gov
  • Social Security Administration: 1-800-772-1213; ssa.gov
  • National Multiple Sclerosis Society Georgia: nationalmssociety.org
  • Parkinson's Foundation Georgia: parkinson.org
  • ALS Association Georgia Chapter: als.org
  • American Stroke Association: stroke.org
  • Alzheimer's Association Georgia: alz.org/georgia

Find personalized help navigating Medicare maintenance therapy coverage at brevy.com.

This guide is provided for educational purposes by Brevy. It does not constitute legal or medical advice. Coverage determinations depend on individual circumstances and contractor application. Consult Medicare, Palmetto GBA, GeorgiaCares SHIP, the Center for Medicare Advocacy, or qualified legal counsel for case-specific guidance. Last verified: 2026-05-14.

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