Hospital Stay Not Covered by Medicare Still Qualifies Recipient for SNF Coverage

A U.S. district court rules that a hospital stay does not have to be covered by Medicare in order to qualify a beneficiary for post-hospital skilled nursing facility benefits as long as the hospital stay was medically necessary. Elder v. Hargan (U.S. Dist. Ct., W.D. N.Y., No. 16-CV-290-FPG, Jan. 26, 2018).

Medicare recipient William Elder entered the hospital to treat broken bones in his leg. After 10 days, the hospital discharged Mr. Elder to a skilled nursing facility (SNF) for rehabilitative services. Medicare denied coverage for the SNF care, ruling that Mr. Elder did not have a qualifying hospital stay before admission and that the SNF services were not reasonable and medically necessary. Medicare also denied coverage of the hospital stay.

Mr. Elder appealed Medicare's decision regarding the SNF care to an administrative law judge (ALJ). The ALJ found that Mr. Elder's stays at the hospital and the nursing facility were medically reasonable and necessary. The Medicare Appeals Council reversed the ALJ's decision, ruling that the ALJ lacked jurisdiction to review the hospital claim because it wasn't up for review. Mr. Elder sued the Secretary of the Department of Health and Human Services in court.

The United States District Court, Western District of New York, grants judgment to Mr. Elder, holding that a hospital stay does not have to be covered by Medicare in order to qualify a beneficiary for post-hospital SNF benefits. According to the court, the ALJ properly considered whether Mr. Elder's hospital stay was medically necessary as part of determining whether Medicare should cover his SNF care.

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