Skilled maintenance therapy under Medicare: the Jimmo Settlement

CMS says the January 2013 Jimmo Settlement Agreement clarified that Medicare covers skilled therapy in the skilled nursing facility, home health, and outpatient therapy benefits when a patient needs skilled care to maintain function or to prevent or slow decline, provided all other coverage criteria are met. CMS says coverage in those settings does not depend on whether the patient is expected to improve. It depends on the patient’s need for skilled care. This applies to physical therapy, occupational therapy, and speech-language pathology. Care that can be safely and effectively carried out by unskilled personnel or caregivers is not covered as skilled therapy.

Quoted from official pages checked November 10, 2026. Confirm current requirements, fees, and dates on those sites. This page is not legal advice and does not guarantee eligibility, certification, or licensure.

CMS’s Jimmo Settlement page, its FAQs (August 2017), its program manual clarifications fact sheet (updated February 3, 2014), and the Medicare Benefit Policy Manual, Chapter 15 were read on November 10, 2026.

What CMS says the settlement did

The Jimmo page states that the agreement “clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).”

For therapy, it states: “Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (‘skilled care’) are necessary for the performance of a safe and effective maintenance program.”

It also states: “In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” The page names outpatient therapy as “physical, occupational, and speech”.

What the FAQs add

The FAQs state: “Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” And: “A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage under these benefits.”

On when skilled therapy is needed, the FAQs state: “Skilled therapy is necessary for the performance of a safe and effective maintenance program only when the needed therapy procedures are of such complexity that the skills of a qualified therapist are needed to perform the procedure, or the patient’s special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled.”

On switching goals, the FAQs answer “Yes.” to whether a patient can change from an improvement course of care to a maintenance course, and say: “The therapy plan of care should indicate the treatment goals based on an individualized assessment or evaluation of the patient.” On a particular diagnosis: “Medicare coverage for skilled nursing or therapy services is not determined solely by a patient’s specific medical condition.”

What the manual says for outpatient therapy

Chapter 15, section 220.2, states: “Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.” Under “Maintenance Programs” it states: “Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance therapy under a maintenance program.”

It describes two kinds of covered service. On establishing a program: “If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered.” On delivering one: “Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care.” It adds: “A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided.” The plan of care itself is described on Medicare therapy plans of care.

Inpatient rehabilitation is different

The FAQs state that “such maintenance coverage standards do not apply to services furnished in an Inpatient Rehabilitation Facility (IRF) or a comprehensive outpatient rehabilitation facility (CORF)”. For IRFs, they say the agreement clarified that “coverage should never be denied because a patient cannot be expected to achieve complete independence in the domain of self-care or because a patient cannot be expected to return to his or her prior level of functioning.” See working in inpatient rehabilitation.

What did not change

The Jimmo page states: “The Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary to diagnose or treat the beneficiary’s condition, or existing statutory limitations on the amount or duration of Medicare benefits.” The fact sheet quotes the agreement: “Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage.”

What this page does not do

It gives no payment figures, therapy thresholds, or diagnosis examples, and it does not decide any claim. CMS directs providers with questions to their Medicare Administrative Contractor. It is not legal, billing, or compliance advice. Confirm current rules with the agency that publishes them, your employer, and your state board.