Medicare 2026

Medicare Doesn't Require You to Improve: What the Jimmo Settlement Means for Maintenance Care

If you've ever been told that Medicare will stop paying for therapy or skilled nursing because a loved one "isn't making progress," you're not alone — and the rule you were told is not the rule Medicare actually follows. A court-approved settlement more than a decade ago made this clear, and it still matters today for people recovering from a stroke, living with Parkinson's disease, managing multiple sclerosis, or coping with any chronic condition where the goal is to hold steady or slow decline rather than fully recover.

Here's what the Jimmo Settlement says, what it doesn't change, and how to use it if you run into a denial.

The background: what Jimmo changed, and what it didn't

On January 24, 2013, a federal court approved the Jimmo Settlement Agreement. It didn't create a new benefit. Instead, it clarified Medicare's longstanding policy: coverage of skilled nursing and skilled therapy in the skilled nursing facility (SNF), home health, and outpatient therapy settings does not turn on whether the patient is likely to get better. It turns on whether the patient needs skilled care.

Before Jimmo, many patients and families heard some version of the "Improvement Standard" — the idea that once a person stopped progressing, Medicare would stop paying. The Centers for Medicare & Medicaid Services (CMS) confirmed that this was never the correct standard. If skilled care is needed to maintain the person's current condition, or to prevent or slow further decline, Medicare can cover it.

What "skilled" really means for maintenance care

The key word is skilled. Medicare will cover therapy for a maintenance program when an individualized assessment shows that the specialized judgment, knowledge, and skills of a qualified therapist are necessary to carry out the program safely and effectively. For example, a therapist may be needed to design a safe exercise routine for someone with advanced ALS, to adjust a program as a condition changes, or to train caregivers.

On the other hand, Medicare will not pay for maintenance services when the activities can be safely and effectively performed by the patient alone or by an unskilled caregiver like a family member or home aide. Once a program can be carried out safely without a therapist, the skilled component — and the Medicare coverage for it — ends.

The same logic applies to skilled nursing. If a nurse's clinical judgment is required to carry out or monitor the care, that care can be covered. If the task could reasonably be handled by a non-nurse, it generally cannot.

When improvement stalls

CMS has been clear that a patient does not need to decline before Medicare will cover medically necessary skilled care. And when someone who was expected to improve stops improving, that is not automatically the end of coverage. If skilled care is still needed, a new plan of care with maintenance goals should be developed. The question is always the same: does the person still need skilled care?

Inpatient rehab is a bit different

The Jimmo maintenance coverage standard applies to SNF, home health, and outpatient therapy — not to inpatient rehabilitation facilities (IRFs), which have their own coverage rules. But CMS has emphasized that inpatient rehab coverage should never be denied simply because a patient is not expected to achieve complete independence in self-care or return to their prior level of functioning. Progress, not perfection, is the measure.

What Jimmo does not change

The settlement left Medicare's other coverage requirements in place:

• Services must still be reasonable and necessary.
• Existing limits on the amount or duration of benefits still apply, including the 100-day limit on Part A SNF care in a benefit period.
• Standard documentation and plan-of-care requirements still apply.

In short, Jimmo removed a barrier, but it did not remove the other rules around the benefit.

Medicare Advantage plans must follow it too

CMS has stated that Medicare Advantage plans must apply the same coverage standards for skilled care as clarified by the Jimmo Settlement. If you're enrolled in a Medicare Advantage plan and you're told that therapy or skilled nursing is ending because the patient isn't improving, that reasoning is not consistent with Medicare policy. Whether you have Original Medicare or a Medicare Advantage plan — each with its own trade-offs around provider networks, cost-sharing, extra benefits, and out-of-pocket exposure — the Jimmo standard applies to the skilled care in question.

What to do if you hear "no improvement, no coverage"

If you or a loved one is told that Medicare won't pay because the patient isn't getting better, consider these steps:

1. Ask for the denial in writing. You need documentation to appeal. 2. Talk with the treating clinician. Ask whether the plan of care should be updated to reflect maintenance goals and whether skilled care is still needed. 3. Use the Medicare appeals process. Both Original Medicare and Medicare Advantage have formal, time-limited appeal rights; the written denial will explain how. 4. Keep records. Notes on function, safety concerns, and why a trained professional is needed strengthen an appeal.

A note on upcoming Medicare basics

While you're getting oriented, two reminders for the broader program: the Part D out-of-pocket cap is $2,400 in 2027 (up from $2,100 in 2026), and Annual Enrollment for 2027 coverage runs October 15 – December 7, 2026, with choices taking effect January 1, 2027. The 2027 Part B standard premium, deductible, and IRMAA income brackets have not yet been announced; CMS typically announces those figures in the fall.

Where can you get help with Medicare questions?

For official information, coverage rules, and the appeals process, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), available 24 hours a day, 7 days a week. The more you understand about what Medicare actually requires — and doesn't require — the better positioned you are to get the care you've earned.