Your mother suffered a stroke. After a hospital stay, she moved to a Skilled Nursing Facility (SNF) for rehabilitation.
For 3 weeks, Medicare paid for her physical therapy, and she was improving.
Then, the facility administrator calls you with bad news:
"We are stopping the therapy. Mom has plateaued. She isn't getting better anymore, so Medicare won't pay."
This is a lie.
It is based on a myth called the "Improvement Standard."
Because of a landmark court settlement known as Jimmo v. Sebelius, Medicare MUST pay for therapy even if your parent never gets better—as long as it prevents them from getting worse.
Disclaimer: This is for informational purposes only, not legal advice. Rules regarding Medicare Advantage (Part C) plans may vary in practice, though they are legally bound by this settlement.
Nursing Home Stopped Mom's Therapy Because She 'Plateaued'?
1. The Myth: "The Improvement Standard"
For decades, nursing homes believed (and taught) that if a patient isn't showing "restorative potential" (getting stronger/better), Medicare cuts off funding.
This meant patients with chronic conditions like Parkinson’s, MS, ALS, or Alzheimer’s were routinely denied care because these diseases naturally worsen over time.
2. The Truth: "Maintenance Therapy" Is Covered
In 2013, a class-action lawsuit (Jimmo v. Sebelius) forced Medicare to clarify its rules.
The New Rule: Coverage does NOT depend on the patient's potential for improvement.
Coverage depends on whether skilled care is necessary to:
- Maintain the patient's current condition.
- Prevent or slow further deterioration.
Example:
If stopping physical therapy would cause your mom's joints to lock up (contractures) or increase her fall risk, Medicare must pay for the therapy to keep her safe, even if she never walks again.
3. Why Facilities Still Lie in 2026
Why did the administrator tell you Medicare won't pay?
Two reasons:
- Ignorance: Many staff members are still trained on old, outdated rules regarding the "plateau."
- Money: "Maintenance Therapy" requires skilled staff but doesn't always improve the facility's "Success Stats" (which they use for marketing). They often prefer to discharge slow-progressing patients to bring in new ones.
4. What To Do If They Try to Cut Coverage
Do not just accept the "Notice of Medicare Non-Coverage" (NOMNC). Fight back immediately.
🛡️ Your Action Plan
- Say the Magic Words: "I am requesting Maintenance Therapy under the Jimmo v. Sebelius settlement. Improvement is not required for coverage."
- Demand a Written Notice: Ask for the official form (NOMNC) stating why coverage is ending.
- Appeal Instantly: Call the QIO (Quality Improvement Organization) phone number listed on the notice. (You usually have until noon of the next day).
- Involve the Doctor: Ask the doctor to write an order stating: "Skilled therapy is necessary to prevent decline."
5. Who Pays If You Win?
If you win the appeal (or if the facility backs down), Medicare Part A continues to pay:
- Days 1–20: 100% of the cost.
- Days 21–100: All costs except for a daily co-pay ($217.00 per day in 2026).
Without this coverage, you would be paying the private pay rate of $400 to $600+ per day out of pocket.
Don't Let Them Give Up on Mom
Just because your parent has a chronic illness doesn't mean they deserve to be abandoned in a bed.
"Maintenance" is a valid medical goal.
Use the power of the Jimmo Settlement. Remind the facility that the law requires them to care for your mother, not just cure her.
Action Plan:
- Google "Jimmo v. Sebelius Fact Sheet CMS" and print it out.
- Bring it to the next Care Plan meeting.
- If they mention "plateau," hand them the paper and ask to speak to the Director of Nursing.
Helpful Resources:
CMS.gov: Official Jimmo v. Sebelius Page
Center for Medicare Advocacy: Jimmo Fact Sheet
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