The Medicare Improvement Standard Myth: What SLPs Should Say and Document

A patient with Parkinson’s disease arrives at an SLP’s office repeating what another provider told them: Medicare stops paying when speech therapy plateaus. The correct answer is that skilled therapy is covered to maintain function or slow decline, with or without improvement. The federal court approved the Jimmo v. Sebelius settlement on January 24, 2013, and a September 2026 report from 247wallst.com shows the myth still circulates in some clinics.

That legal baseline is settled. What remains uneven is the documentation language clinicians use, the scripts patients hear, and the follow-through after a denial. The gap between the rule and the front desk is the clinical risk.

What Jimmo V. Sebelius Actually Requires

The improvement standard was never part of the Medicare statute. Jimmo v. Sebelius, approved on January 24, 2013 by the U.S. District Court for the District of Vermont, settled a nationwide class action over skilled nursing facility, home health, outpatient therapy, and inpatient rehabilitation facility denials. The class was represented by the Center for Medicare Advocacy and Vermont Legal Aid.

A settlement, not a new statute

The plaintiff class included people with Parkinson's disease, multiple sclerosis, ALS, and lasting effects of stroke. Those are the conditions SLPs see daily in Geriatric Speech Therapy: aphasia, dysphagia, cognitive-communication disorders, and progressive speech or swallowing decline often require skilled maintenance, not measurable gains. CMS revised its Medicare Benefit Policy Manual to state that coverage "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."

Manual revisions and a corrective statement

CMS later issued a corrective statement confirming that no improvement standard applies to skilled nursing facility, home health, outpatient therapy, and inpatient rehabilitation facility. That corrective action came after the initial manual revisions still left some contractors leaning on improvement expectations. Skilled care may be medically necessary to improve a condition, maintain current function, prevent decline, or slow deterioration. For SLPs, this means a maintenance plan for chronic communication or swallowing decline is not automatically denied solely because the patient has plateaued.

What Jimmo does not do

Jimmo does not guarantee payment for every visit. Coverage still requires that the service be skilled, reasonable, and necessary, and that all other Medicare criteria are met. As 247wallst.com reported in September 2026, some clinics still repeat the plateau myth. SLP documentation should reflect the settled rule, not the myth, and align with speech therapy documentation requirements.

Why the Improvement Myth Persists in 2026

In 2026, the legal rule has been settled since the 2013 Jimmo settlement, yet many SLP practices still hear "Medicare stops when progress stops." The myth survives for predictable reasons.

Old habits and progress-focused training

Clinic templates, contractor denials, and productivity systems often still reward measurable improvement. Graduate programs and SLP clinical practicum tend to teach goals built around progress, so maintenance goals can feel less billable even when the skill needed is clearly there. Some referral sources repeat the same shorthand because it is simpler than explaining skilled maintenance.

Medicare Advantage must follow Jimmo

At the coverage-criteria level, yes. Under 42 CFR 422.101 and the 2024 CMS-4201-F final rule, Medicare Advantage plans must cover the same Part A and Part B basics and apply Traditional Medicare standards, including Jimmo.¹ They may not use internal criteria to deny skilled maintenance solely because it maintains function, lacks expected improvement, or looks custodial without an individualized skilled speech therapy assessment. What remains less clear is operational enforcement: prior authorization, reviewer training, and plan-specific workflows still produce denials that sound like the old improvement standard, and day-to-day application varies.

The clinical cost

When the myth goes unchallenged, SLPs discharge patients with aphasia, Parkinson's disease, or post-stroke cognitive-communication needs who still require a licensed therapist's skill to maintain function or slow decline.

The Three Tests That Decide Skilled Therapy Coverage

Medicare decides speech therapy coverage the same way it decides other skilled care: by asking whether the service needs a licensed clinician's judgment and skill, not by whether the patient is improving. Three tests matter.

The three tests

• Skilled care is required. Services must require the skills of a qualified speech-language pathologist. Coverage is not automatic just because an SLP provides the visit. The record should show why the patient, family, or a nonskilled caregiver cannot safely or effectively carry out the activity.
• The plan of care is certified. A physician-certified plan is required, including diagnoses, type, amount, frequency, and duration of services. Setting rules differ: outpatient Part B follows Medicare Benefit Policy Manual Chapter 15; home health and skilled nursing facility care add their own coverage conditions.
• The care is reasonable and necessary. Care must be reasonable and necessary for the patient's illness or injury. The manual states that skilled therapy may improve, maintain, or prevent or slow deterioration, so a plateau or decline does not by itself end coverage.

Skilled maintenance vs. custodial help

Article A52866 recognizes maintenance or prevention as a valid coverage goal when there is a reasonable expectation at the start of care, even if the desired outcome is not fully achieved. A skilled SLP might adjust a dysphagia program and retrain a caregiver as swallowing status changes; a custodial service is a stable routine a caregiver can safely follow without clinician judgment. Caregiver training may be covered when it is part of that skilled plan.

What the progress note should show

Rehabilitative records track expected measurable improvement. Maintenance records should explain the goal of maintaining or slowing decline and why continuing SLP involvement is needed. In skilled nursing facility SLP settings, a progress report is generally required at least every 10 treatment days.

How to Document Skilled Maintenance Therapy

The hardest shift for many SLPs is not clinical; it is documentation. Graduate programs and clinical placements train clinicians to write goals that show measurable gains, but Medicare's Jimmo standard asks for evidence that skilled care is needed to maintain function or slow decline, even when a patient's baseline has flattened.

A Five-Step Documentation Checklist

• Functional maintenance goal: Frame the goal as preventing decline or preserving independence, not just "maintain." Example: "Patient will maintain the ability to communicate basic wants and needs during meals using trained swallowing-safety strategies."
• Objective baseline and measures: Record a quantified baseline at the start of treatment and collect the same measure during or after treatment to show stability or slowed decline.
• Rationale for SLP skill: Explain why the activity requires a licensed speech-language pathologist's assessment, cueing, modification, or training, rather than routine reminders by caregivers.
• Reassessment schedule: Note when you will recheck the measures, typically by the 10th treatment day for a progress report.
• Why the plateau does not end medical necessity: State that continued skilled care is needed to prevent avoidable complications, such as aspiration or loss of functional communication, even if scores are unchanged.

Sample Progress-Note Language

These are illustrative only and should be individualized.

• "Patient remained at baseline for two-step auditory comprehension but required maximal cueing to safely sequence thickened-liquid swallows; SLP modified the pacing strategy and trained the spouse in visual cues to reduce aspiration risk."
• "Word-finding accuracy showed no change today, yet the patient used trained self-cueing only after SLP modeled it twice, indicating continued need for skilled practice to preserve independence."
• "AAC navigation stayed at 80% without caregiver prompting, but layout changes required skilled reprogramming and retraining to keep communication safe."

What to Avoid

• Writing "no progress" or "plateaued" without a skilled-need statement.
• Goals that only say "maintain" with no functional target, measurement, or medical necessity rationale.
• Documenting the patient's presence without recording clinical reasoning for modifications or training.

ASHA's Medicare documentation guidance reinforces this: goals should be measurable and functional, and each daily note should connect the skilled service to the goal, the objective data, and the next clinical decision.

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Maintenance Scenarios: Aphasia, Parkinson's, Dysphagia and Cognitive-Communication

The scenarios below show how maintenance goals can be framed under the Jimmo standard. Each row is an example only; coverage is always based on individual clinical findings, and these examples are not promises of outcomes.

Talking Points for Patients, Families, and Referral Sources

The most damaging conversation starts with "Medicare stops paying when you plateau." The useful conversation starts with "Medicare covers skilled therapy to maintain function or slow decline, when a licensed SLP's skill is needed."

Patient told "Medicare stops when you stop improving"

• "That is not the rule. Medicare can cover speech therapy to maintain your communication or swallowing, or to slow loss, when my skilled care is medically necessary. It is not automatic. Coverage depends on the skilled need and my documentation, not on showing constant improvement."

Family worried about plateau discharge

• "Do not accept a discharge just because progress has stalled. Ask whether the therapist can document skilled maintenance for your family member's condition. If the plan requires an SLP's judgment, Medicare can still cover it even without measurable improvement."

Referring physician or PT

• "If a patient with aphasia, Parkinson's disease, or post-stroke cognitive-communication deficits is not showing measurable change, the referral is still appropriate. Send the patient and ask the SLP to assess whether skilled maintenance is medically necessary. That standard comes from Jimmo v. Sebelius, not an improvement rule."

The $2,480 threshold and KX modifier

"Original Medicare does not cap speech therapy. In 2026, after physical therapy and speech-language pathology combined reach $2,480, the clinic attaches a KX modifier confirming the care continues to be medically necessary. Families may hear about a threshold or targeted review, but not an automatic stop at that dollar amount."

Give them a written summary

"Hand families a short one-pager that explains the Jimmo standard, the threshold, and Speech-Language Advocacy steps, and point them to Medicare.gov or their State Health Insurance Assistance Program (SHIP)."

If Coverage Is Denied: ABNs, Appeals, and SHIP Counselors

When an ABN comes into play

An Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, applies to Original Medicare beneficiaries when the provider expects Medicare may deny a service. It is not an appeal decision. Patients can sign the ABN and accept financial responsibility for the service, or decline the service and avoid the charge. Signing the ABN does not remove the right to appeal a later denial. Medicare Advantage plans use their own notices instead of this form.

Original Medicare appeal steps

For Original Medicare, a denial can be fought through five levels.¹ Start with a written redetermination request to the Medicare Administrative Contractor. The standard decision timeframe is 60 days, or 72 hours if the patient qualifies for expedited review. Deadlines generally run from receipt of the decision notice, and late appeals may be accepted for good cause. If the redetermination fails, request reconsideration within 180 days of receiving the decision.¹ In both the redetermination and reconsideration, cite Jimmo v. Sebelius and the CMS manual language stating that no improvement standard applies. The appeal should frame the SLP care as skilled maintenance that is medically necessary to maintain function or slow decline. If reconsideration is also denied, the next level has a $200 amount-in-controversy threshold and a 60-day filing deadline.¹

Medicare Advantage appeals

Medicare Advantage denial notices follow a different path. The first step is a plan reconsideration, requested within 65 days of the denial notice.² After the plan's reconsideration, the next level is the independent review entity. The plan's denial and appeal instructions set the decision timeline, so patients should use the deadlines in their notice rather than assume Original Medicare rules apply. Expedited review may be available if waiting could seriously harm the patient's health or ability to regain function.

Free help and SLP documentation

Patients can get free local Medicare counseling through the State Health Insurance Assistance Program at shiphelp.org or 1-877-839-2675.³ Clinicians should keep progress notes, maintenance goals, and the rationale for skilled care ready so the appeal has what it needs.

Where to Report Clinics That Misapply the Improvement Standard

Start with 1-800-MEDICARE (1-800-633-4227; TTY: 1-877-486-2048) to report an Original Medicare denial or to get the correct number for your state's Beneficiary and Family Centered Care QIO.¹ Have the denial date, written reason, and clinic name on hand.

• 1-800-MEDICARE: Handles benefits questions, unresolved Original Medicare concerns, and can direct you to your state's QIO.¹ Keep dates, denial letters, and notes ready.
• Medicare Administrative Contractor: For claim-specific coverage problems, follow the contact directions in the decision letter.³ There is no single nationwide MAC complaint line, so use the notice's route and keep the denial letter attached.
• BFCC-QIO: Handles complaints, grievances, quality-of-care reviews, and medical-necessity reviews.² Include the therapy service, payer, clinic, written denial reason, and treatment goals.⁵ Depending on the state, the QIO is administered by either Commence Health or Acentra.²
• Medicare Advantage: File a grievance with the plan's customer-service number first. If the plan does not resolve it, contact 1-800-MEDICARE or the applicable state insurance department about plan conduct.⁴

No single channel is exclusively for misuse of the improvement standard; choose the route tied to the payer. SLPs can also raise a clinic's pattern with its compliance officer before external reporting. Filing a complaint does not replace an appeal if the goal is to overturn a payment decision.³