Medicare Required to Cover Long-Term Rehabilitation

Medicare Required to Cover Long-Term Rehabilitation Even if Prior Hospitalization Is Not Covered

The United States District Court for the District of New York has recently ruled that Medicare must cover a long-term care stay at a skilled nursing facility, even if the preceding hospital stay was not covered under Medicare, since 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.

William Elder was in the hospital for ten days for treatment of broken bones in his leg.  He was subsequently discharged to a skilled nursing facility (“SNF”) for rehabilitation.  Medicare denied payment for the rehabilitative services on the grounds that “Mr. Elder did not have a qualifying hospital stay prior to being admitted” to the SNF.  Mr. Elder appealed that denial of benefits administratively, and eventually the case was heard in the district court of New York. 

The district court held that as a matter of law, Medicare coverage for treatment in a SNF is appropriate if the Medicare recipient’s prior hospital stay is medically necessary, whether or not the hospital stay is actually covered by Medicare.  Thus, Mr. Elder’s SNF stay should have been covered by Medicare.

Unfortunately, Mr. Elder was required to argue his claim repeatedly in order to obtain coverage for a $5,850.00 bill, even though the law was clearly on his side.  This case can therefore be seen as an incentive to plan ahead for long-term care costs, and a warning not to assume that Medicare will take care of you when you most need it.

If you have any questions about the issues presented above or care to discuss any other planning issues, please call us at 860-769-6938, visit our website at http://www.weatherby-associates.com or email us at info@weatherby-associates.com.

 

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