A beneficiary was not entitled to coverage for her stay at a skilled nursing facility (SNF) from her Medicare Advantage (MA) organization because the MA was not required to provide coverage for care provided at a SNF without a preceding three day hospital stay. MA organizations are not required but may elect to furnish, as part of their Medicare covered benefits, coverage of post-hospital SNF care in the absence of a prior qualifying hospital stay under the provisions of 42 C.F.R. §422.101(c). The final decision of the Secretary was affirmed.
Three day prior hospitalization
Generally, as stated in 42 C.F.R. §409.30(a), in order for a beneficiary to receive Medicare coverage for post-hospital SNF care, the beneficiary must have been an inpatient in a qualifying hospital for at least three consecutive calender days. In accordance with this regulation, MA organizations are required to provide coverage of post-hospital extended care services at a SNF where a beneficiary has met the three-day qualifying hospital stay requirement and other requirements for Medicare coverage and payments.
However, MA organizations may elect to furnish as part of their Medicare covered benefits, coverage of post-hospital SNF care, in the absence of a qualifying hospital stay. The court held, substantial evidence in the record supports the finding that this MA did not elect to provide this benefit. The evidence includes: (1) informational material provided by the MA to enrollees that a three day hospital stay was required before SNF care would be covered; (2) the beneficiary was informed by the MA upon her admission to the SNF that the MA would not cover her stay; and (3) nothing in the MA's policy or other written materials supports the beneficiary's claim that the MA had a policy of making available a waiver of the qualifying hospital stay.
Furthermore, the court found that the beneficiary did not qualify for coverage of SNF services even though her doctor determined that a direct admission to a SNF without a three day hospital stay was medically appropriate.
Source: Rapport v. Leavitt, W.D.N.Y., July 9, 2008.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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