Medicare Maintenance Therapy: The Jimmo Standard

Many clinicians still practice as though Medicare only pays for physical, occupational, and speech therapy when a patient is expected to get better. That belief, sometimes called the “Improvement Standard,” was never accurate as policy, and a federal settlement said so in writing. The Jimmo v. Sebelius settlement agreement, approved by the court in January 2013, led CMS to clarify that skilled nursing and skilled therapy coverage in the SNF, home health, and outpatient therapy benefits “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” (CMS Jimmo Settlement page).

The settlement did not expand what Medicare covers. The agreement states that nothing in it “modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage” (Jimmo Settlement Agreement), and CMS notes it leaves every other coverage requirement in place, including the requirement that services be reasonable and necessary (CMS Jimmo Settlement page). CMS also didn’t get compliance right on the first attempt. In August 2016 the court granted the plaintiffs’ motion to enforce, finding the government’s educational campaign fell short of the settlement’s terms (Jimmo v. Burwell, D. Vt., August 2016 opinion), and its February 2017 corrective action order, which required a dedicated Jimmo webpage, a corrective statement, a new national call, and new contractor training, is why the current CMS Jimmo page, corrective statement, and FAQs exist at all (Jimmo v. Burwell, D. Vt., February 2017 order).

For a therapist or clinic owner, the settlement raises practical questions the top search results don’t fully answer: what a maintenance program actually covers, who can deliver it, how to document it, and how it interacts with the KX threshold and ABNs. This guide works from the manual’s own two-prong skilled test, the setting-by-setting delivery rules including a PTA/OTA delegation rule the manual hasn’t caught up to, and the documentation phrases CMS calls insufficient. Current as of September 2026.

Does Medicare require improvement for therapy coverage?

No, and the settlement’s own definition of what it was fighting makes that clear. The agreement defines the “Improvement Standard” as an alleged practice under which “Medicare coverage of skilled services is denied on the basis that a Medicare beneficiary is not improving, without regard to an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care or services in question” (Settlement Agreement, Definition 9). CMS denied that standard was official policy, but agreed to revise its manuals so contractors couldn’t apply one.

Those revisions arrived as Change Request 8458 and touched chapters 7 (home health), 8 (SNF), and 15 (outpatient therapy) of the Medicare Benefit Policy Manual. CMS’s fact sheet is explicit that these were clarifications, not new coverage. It adds that “Medicare has never supported the imposition of an ‘Improvement Standard’ rule-of-thumb” (Jimmo fact sheet).

The standard follows the beneficiary, not the payer: Medicare Advantage plans “must apply the standards for coverage of skilled care as clarified by the Jimmo Settlement Agreement” the same as original Medicare (Jimmo FAQs, A15).

What counts as a covered maintenance program?

The manual’s definitions section describes a maintenance program as “a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness” (Benefit Policy Manual, §220 definitions). Not every piece of that program is automatically skilled, and the manual’s two-prong test is what separates a covered service from one a caregiver could do unsupervised: skilled care is necessary “only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures” (Benefit Policy Manual, §220.2.D).

That test maps onto three distinct pieces of a maintenance program, and coverage of each piece is decided separately:

If a service “can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service,” and general exercises for overall fitness or diversion “do not constitute therapy services for Medicare purposes” at all (Benefit Policy Manual, §220.2.A).

The manual’s own examples show the test in action, all per §220.2.D. A Parkinson’s patient nearing the end of rehabilitative PT: the therapist’s final weeks designing the program, instructing the patient or family, and reassessing it are covered. An MS patient not currently in therapy who needs an SLP to build a program slowing communication decline: design and training are covered, but once built, “the skills of a therapist are not required to actually carry out the maintenance program services and, as a result, are not covered.” A patient with an unhealed, unstable fracture: delivery itself is covered, because skill may be needed “to ensure that the fractured extremity is maintained in proper position and alignment during range of motion exercises.” A long-standing MS patient with spasticity needs a PT’s skill to instruct in transfers and stretching, but once the patient can do so safely alone or with a caregiver’s help, “the skills of the physical therapist are no longer necessary,” and the patient is discharged.

A patient can also move from a rehabilitative course to a maintenance course, and back. When a patient who was expected to improve stops improving, the therapist must determine whether skilled care is needed to maintain the patient’s condition or slow decline, and if it is, “a plan of care to reflect the new maintenance goals must be developed.” Medicare “does not require a patient to decline” first, and “a comprehensive treatment plan does not require all disciplines to have the same goals” (Jimmo FAQs, A7, A9, A11, A12).

Who can deliver maintenance therapy visits?

Coverage runs through three benefits, each governed by its own regulation, and they don’t all treat assistants the same way.

Home health draws the sharpest line: the program itself “must be established by a qualified therapist (and not an assistant),” while delivery “may require the specialized skills of a qualified therapist or therapist assistant” (42 CFR 409.44(c)(2)(iii)). SNF regulation never made that distinction: CMS removed “(not an assistant)” from the SNF manual chapter because “the regulations under 409.32(a) and (b) do not specify that an assistant cannot perform maintenance services in the SNF setting, unlike the home health and outpatient regulations which do make that distinction” (Transmittal 179, CR 8458). Outpatient Part B, 42 CFR 410.60, pays for PT furnished by a qualified therapist or “an appropriately supervised physical therapist assistant,” without distinguishing rehabilitative from maintenance services at all (42 CFR 410.60); what that means for PTAs and OTAs specifically is next.

Chiropractic is the exception to all of this: the same manual states that “Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable” (Benefit Policy Manual, §30.5.B); see our chiropractic Medicare billing guide if that’s the setting you bill in.

Can PTAs and OTAs deliver maintenance therapy under Medicare?

Here the regulation and a final rule control, and the manual has not caught up. As of the chapter’s July 30, 2026 revision (Rev. 13889), §230.1 still states that “PTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage, or furnish skilled maintenance program services; or take responsibility for the service,” and §230.2 says the identical thing about OTAs (Benefit Policy Manual, §230.1, §230.2). That language dates to Transmittal 179, January 2014, and hasn’t been revised since.

It is superseded. In the CY 2021 Physician Fee Schedule final rule, CMS finalized, on a permanent basis, that PTs and OTs may delegate maintenance therapy delivery to a PTA or OTA in outpatient Part B settings “as clinically appropriate,” effective January 1, 2021. CMS chose not to amend the underlying regulations, which “do not distinguish between rehabilitative and maintenance therapy services,” and said it would revise manual sections 220.2, 230.1, and 230.2 instead. That manual revision has not appeared. The implementing transmittal states the effect plainly: “This finalized policy allows Physical Therapists (PT) and Occupational Therapists (OT) to delegate the furnishing of maintenance therapy services, as clinically appropriate, to a Physical Therapy Assistant (PTA) or an Occupational Therapy Assistant (OTA)” (Transmittal 10505, CR 12071).

In practice: treat §230.1 and §230.2’s “may not… furnish skilled maintenance program services” as stale for outpatient Part B delivery. The regulation and the CY 2021 final rule control, the same pattern our PTA/OTA supervision guide found in the manual’s supervision language. A delegated maintenance visit still carries the CQ or CO modifier and, since January 1, 2022, is paid at 85 percent like any other assistant-furnished service (CY 2021 PFS final rule); see our CQ/CO modifier guide for the mechanics. The rule addresses PTAs and OTAs only.

How do you document a maintenance program so it survives review?

Start with the plan of care. Regulation requires diagnoses, long-term goals, and the type, amount, duration, and frequency of services; the manual adds that “goals should be measurable and pertain to identified functional impairments” (Benefit Policy Manual, §220.1.2.B; see our plan of care and certification guide). Progress reports are due at least once every 10 treatment days (Benefit Policy Manual, §220.3.D), and it’s there a maintenance justification holds up or doesn’t; our documentation requirements guide covers the cycle.

CMS has named the specific phrases it considers too vague to establish coverage:

(Vague phrases per Jimmo fact sheet.) What CMS wants instead: “justification for treatment would include, for example, objective evidence or a clinically supportable statement of expectation that, in the case of maintenance therapy, the skills of a qualified therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers” (Jimmo FAQs, A8). The manual’s progress report rules require the same showing: “treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel” (Benefit Policy Manual, §220.3). If a patient plateaus and treatment continues, the manual recommends documenting the reason along with the justification for continuing (Benefit Policy Manual, §220.3).

The templates below are illustrative only, modeled on the manual’s own examples, not patient records or real outcomes. Any pronoun refers to a hypothetical patient.

Establishing a program near the end of rehabilitative care (modeled on the manual’s Parkinson’s disease example). Goal: “Establish a home maintenance program addressing [functional domain]; instruct the patient and their caregiver in safe, independent performance; complete a final reassessment confirming they can carry it out safely.” Justification: “The therapist’s skilled judgment is required to design this program and instruct the patient and caregiver. Once that’s complete, a therapist’s skills are no longer required to carry out the program (§220.2.D).”

Skilled delivery required by medical complexity (modeled on the manual’s unhealed fracture example). Justification: “Because the fracture is unhealed and unstable, a qualified therapist’s skill is required to keep the extremity in proper position and alignment during range of motion exercises. This complexity, not the maintenance goal alone, makes the service skilled (§220.2.D).”

Discharge once skilled need ends (modeled on the manual’s long-history MS with spasticity example). Justification: “The patient and their caregiver can now carry out transfers and stretching safely without the therapist’s direct involvement. A physical therapist’s skills are no longer necessary, and the patient is discharged from skilled PT (§220.2.D).”

How does maintenance therapy affect the KX threshold and ABNs?

Maintenance visits are still Part B outpatient therapy visits, and their cost accrues toward the KX threshold exactly like rehabilitative visits do. For CY 2026 that threshold is $2,480, with a separate $3,000 targeted medical review threshold (CMS Therapy Services page; Transmittal R13437CP); see our KX modifier and threshold guide for how the two work together. The KX modifier itself is “a confirmation that services are medically necessary as justified by appropriate documentation in the medical record” (CMS Therapy Services page), so it belongs on a maintenance claim exactly when the two-prong test above is met and the chart says so. PrismEHR tracks accrued therapy expenses per beneficiary against the KX threshold as claims are documented, which matters most when rehabilitative and maintenance visits mix in the same benefit period.

The threshold question and the coverage question are separate, though. The moment the two-prong test stops being met, whether that’s the discharge scenario above or a program a caregiver can now run alone, the visit is no longer skilled. Manual §220.2.D is direct: such services “are not reasonable or necessary and are not covered under §1862(a)(1)(A) of the Act” (Benefit Policy Manual, §220.2.D). To shift liability for that visit to the patient, the provider “must issue a valid ABN, Form CMS-R-131” (Benefit Policy Manual, §220.2.B), and because the service is not reasonable and necessary, that is a mandatory Advance Beneficiary Notice with the GA modifier, not an optional one; our ABN and modifiers guide covers when GA is required.

Maintenance programs raise exactly the kind of billing question a busy practice doesn’t want to work out by hand: is this visit still skilled, and is it still accruing toward the KX threshold. PrismEHR tracks accrued therapy expenses per beneficiary against the KX threshold as claims are documented, and lets organizations define their own billing rules, including minute and unit restrictions, enforced at the point of documentation. PrismEHR also serves wellness practices, which matters to a clinic whose patients graduate out of skilled maintenance care and into a cash-pay program.