Chief Federal District Judge Geraci’s January 26, 2018 decision in Elder v. Hargan, Case # 16-CV-290 FPG (WDNY), opens up a new door to obtaining Medicare coverage of medical care in a skilled nursing facility. Noting the Secretary of Health and Human Services had misinterpreted her own regulations, Judge Geraci found “…[t]he regulations clearly contemplate the ability of a beneficiary to receive Medicare coverage of SNF care even when they were denied coverage for their previous hospital stay.” No appeal has been filed and the opportunity to appeal is closed, making this decision final.
In this case brought by CELJ on Mr. William Elder’s* behalf, third year UB Law Student Neal Johnson’s finely crafted Memoranda of Law carried the day. Mr. Elder is a Salamanca native and currently an Olean resident. The judge ordered Medicare coverage of Mr. Elder’s stay at a Salamanca nursing home.
Though the regulations at issue have long been in place, Medicare contractors’ practice has been to deny coverage for skilled nursing facility care for the sole reason that hospital coverage has been denied, even if the nursing home stay would otherwise be covered. For various reasons, many beneficiaries don’t appeal hospital coverage denials, often because they have been relieved of financial responsibility for the hospital bill. Since “a 3-day medically necessary hospital inpatient stay” is required to obtain coverage of skilled nursing facility care, those beneficiaries have lost out on obtaining Medicare coverage of a subsequent nursing home stay.
After this decision, so long as the beneficiary manages to appeal a nursing home coverage denial up to the Administrative Law Judge level, he or she at least has a chance to obtain Medicare coverage of up to 100 days in a skilled nursing facility. A copy of the decision is below.Elder Decision–Geraci12914094088
*The Center for Elder Law and Justice has obtained Client’s permission to use his name.