Bryan v. United States Secretary of Health & Human Services

758 F. Supp. 1092, 1990 U.S. Dist. LEXIS 18474, 1990 WL 269888
CourtDistrict Court, E.D. North Carolina
DecidedDecember 10, 1990
DocketNo. 90-300-CIV-5-F
StatusPublished
Cited by1 cases

This text of 758 F. Supp. 1092 (Bryan v. United States Secretary of Health & Human Services) is published on Counsel Stack Legal Research, covering District Court, E.D. North Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bryan v. United States Secretary of Health & Human Services, 758 F. Supp. 1092, 1990 U.S. Dist. LEXIS 18474, 1990 WL 269888 (E.D.N.C. 1990).

Opinion

ORDER

JAMES C. FOX, Chief Judge.

STATEMENT OF THE CASE

This case arises under the Medicare program, Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (“Health Insurance for the Aged and Disabled”). Plaintiff is the executor of the estate of a Medicare Beneficiary (the “Beneficiary”). Plaintiff, appearing pro se, seeks judicial review of a final decision of the Secretary of Health and Human Services (the “Secretary”), claiming that the Beneficiary was not sufficiently reimbursed by the Secretary for services rendered to the Beneficiary during June of 1987.1

In the decision which plaintiff challenges, the Secretary disallowed costs incurred by the Beneficiary pursuant to a stay in a nursing facility following her release from a hospital. The Secretary disallowed these costs on the ground that the Beneficiary received “custodial care” in the nursing facility, rather than “skilled nursing care,” and hence was excluded from receiving Medicare benefits therefor.

This matter is now before the court on cross motions for summary judgment. For the reasons set forth below, the court finds that the Secretary’s decision is consistent with the express prohibition of the Medicare Act and regulations that Medicare payments not be made to a beneficiary for care in a nursing facility which is merely custodial in nature. The decision of the Secretary is supported by substantial evidence in the record and is in accordance with law. Therefore, the court denies plaintiff’s motion for summary judgment and grants defendants’ motion for summa[1094]*1094ry judgment, thereby affirming the administrative decision of the Secretary.

STATEMENT OF THE FACTS

1. Operation of the Medicare Program.

The Medicare program was established to provide a system of health insurance for the aged and disabled. Social Security Amendments of 1965, Pub.L. No. 89-97, § 102(a). The program is divided into two parts. Part A2, known as the “health insurance program,” provides insurance for inpatient hospital and related post-hospital (“extended care”) services. 42 U.S.C. § 1395d, 42 C.F.R. § 409.30. To qualify for extended care coverage, a beneficiary must have been a hospital inpatient for at least three days and must have been admitted to a skilled nursing facility for care relating to the hospitalization within thirty days after discharge from the hospital. 42 U.S.C. § 1395x(i).

Under Part A, a beneficiary is entitled to have payment made on his behalf for specific post-hospital extended care services. 42 U.S.C. § 1395d(a). No payment shall be made under Part A, however, where such expenses are for “custodial care.” 42 U.S.C. § 1395y(a)(9). With respect to coverage for post-hospital stays at skilled nursing facilities, the Secretary defines “custodial care” as care which fails to meet the requirements for coverage as “skilled nursing care.” 42 C.F.R. § 405.310(g).

“Skilled nursing care” is that level of care which, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis. 42 U.S.C. § 1395f(a)(2)(B). Under the regulations, the concepts of “skilled nursing care” services and “skilled rehabilitative services” are further defined as those services which “(1) [a]re ordered by a physician; (2) [rjequire the skills of technical or professional personnel such as registered nurses, licensed practical ... nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and (3) [ajre furnished directly by, or under the supervision of, such personnel.” 42 C.F.R. § 409.31(a). Said services are sufficiently complex that they can be safely and effectively performed only by such persons. 42 C.F.R. § 409.32. The regulations proceed to provide many examples of skilled care which make clear that Medicare will pay for a wide variety of services if needed by the patient. See 42 C.F.R. § 409.33 (e.g. intravenous or intramuscular injections, gastrostomy feedings, treatment of decubitus ulcers).

Even where the level of care is custodial in nature, Medicare may pay for all or some of the charges under certain circumstances. Where neither the beneficiary nor the nursing home has reason to know that payment will be disallowed, the Secretary may make payment under waiver. 42 C.F.R. § 405.330(a). Payment will only be made for periods of time during which the beneficiary and the provider are unaware of the disallowance. 42 C.F.R. § 405.334.

Under the Medicare program, the providers of covered services enter into agreements with the Secretary to provide Medicare beneficiaries with a broad range of nursing and rehabilitation services; the facilities agree to charge Medicare beneficiaries only the statutorily mandated deductible and coinsurance amounts, 42 U.S.C. § 1395cc(a), and otherwise to receive payment solely from the Medicare Trust Fund. Payment to providers of Part A covered services is made by non-governmental organizations under contract with the Secretary (in this case, Blue Cross and Blue Shield of North Carolina) known as “fiscal intermediaries.” 42 U.S.C. § 1395h.

The intermediaries also act as the Secretary’s agents in reviewing Medicare claims. See id.; Athens Community Hosp., Inc. v. Schweiker, 743 F.2d 1 (D.C.Cir.1984). Subject to certain amount in controversy limitations not here in issue, an individual dissatisfied with the intermediary’s decision to deny benefits may obtain an administrative hearing and, later, judicial review. 42 [1095]*1095U.S.C. § 1395ff(b), incorporating 42 U.S.C. §§ 405(b), (g). By regulation, the Secretary also has provided for post-hearing administrative review by the Appeals Council; the Council itself initiates this review when appropriate. 42 C.F.R. § 405.724; 20 C.F.R.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
758 F. Supp. 1092, 1990 U.S. Dist. LEXIS 18474, 1990 WL 269888, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bryan-v-united-states-secretary-of-health-human-services-nced-1990.