On June 25, 2024, the Center for Medicare Advocacy requested federal court review of a fundamentally erroneous decision regarding coverage of skilled nursing facility (SNF) care.
The case involves services for a Connecticut resident who was dully-eligible for both Medicare and Medicaid benefits. After a hearing with an Administrative Law Judge (ALJ), the Center won Medicare coverage of the beneficiary’s SNF services because he received “daily, skilled rehabilitation services” in the form of occupational therapy. Medicare law is definitive about covering SNF care when qualified beneficiaries receive “daily skilled” care, which can be either nursing services or rehabilitation services (such as physical or occupational therapy). However, after the ALJ issued a favorable decision, a Medicare contractor stepped in and referred the decision to the next level of appeal—the Medicare Appeals Council—for additional review. Misreading the controlling law and regulations, the contractor claimed that coverage of inpatient SNF services can only be based on daily skilled nursing services, and not on daily skilled rehabilitation services. Alarmingly, the Appeals Council agreed with this blatant misstatement of the law and found that Medicare could not cover the SNF care in question.
It is particularly troubling that CMS’s contractor went out of its way to overturn a duly-considered and legally correct ALJ decision, and that the Appeals Council – the highest level of review in Medicare’s administrative appeal system – affirmed the incorrect argument. It indicates a quality-control problem within Medicare’s administrative appeal system. Unfortunately, it is difficult to correct even obvious errors in that system. The Center requested that the Appeals Council “reopen” the decision, but the Council is experiencing severe delays – regularly lasting several years – in responding to requests from litigants. Thus, to protect beneficiaries’ interests and prevent this misstatement of law from threatening coverage of other critically-needed SNF services, the Center appealed the Council’s decision to federal district court on behalf of Connecticut’s Department of Social Services, which bore the costs of the services that Medicare should have paid for.
The Center hopes that a swift resolution of this basic question of Medicare law will be forthcoming.
- Read the complaint in Barton Reeves v. Becerra, No. 3:24-cv-01097 (D. Conn.)