C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 409—HOSPITAL INSURANCE BENEFITS › Subpart D—Requirements for Coverage of Posthospital SNF Care

42 C.F.R. § 409.30

Basic requirements

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Posthospital SNF care, including SNF-type care furnished in a hospital or CAH that has a swing-bed approval, is covered only if the beneficiary meets the requirements of this section and only for days when he or she needs and receives care of the level described in § 409.31. A beneficiary in an SNF is also considered to meet the level of care requirements of § 409.31 up to and including the assessment reference date for the initial Medicare assessment prescribed in § 413.343(b) of this chapter, when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. For the purposes of this section, the assessment reference date is defined in accordance with § 483.315(d) of this chapter, and must be set for no later than the eighth day of posthospital SNF care.

(a) Pre-admission requirements. The beneficiary must—

(1) Have been hospitalized in a participating or qualified hospital or participating CAH, for medically necessary inpatient hospital or inpatient CAH care, for at least 3 consecutive calendar days, not counting the date of discharge; and

(2) Have been discharged from the hospital or CAH in or after the month he or she attained age 65, or in a month for which he or she was entitled to hospital insurance benefits on the basis of disability or end-stage renal disease, in accordance with part 406 of this chapter.

(b) Date of admission requirements.1 (1) Except as specified in paragraph (b)(2) of this section, the beneficiary must be in need of posthospital SNF care, be admitted to the facility, and receive the needed care within 30 calendar days after the date of discharge from a hospital or CAH.

1 Before December 5, 1980, the law required that admission and receipt of care be within 14 days after discharge from the hospital or CAH and permitted admission up to 28 days after discharge if a SNF bed was not available in the geographic area in which the patient lived, or at the time it would be medically appropriate to begin an active course of treatment, if SNF care would not be medically appropriate within 14 days after discharge.

(2) The following exceptions apply—

(i) A beneficiary for whom posthospital SNF care would not be medically appropriate within 30 days after discharge from the hospital or CAH, or a beneficiary enrolled in a Medicare + Choice (M + C) plan, may be admitted at the time it would be medically appropriate to begin an active course of treatment.

(ii) If, upon admission to the SNF, the beneficiary was enrolled in an M + C plan, as defined in § 422.4 of this chapter, offering the benefits described in § 422.101(c) of this chapter, the beneficiary will be considered to have met the requirements described in paragraphs (a) and (b) of this section, and also in § 409.31(b)(2), for the duration of the SNF stay.

[48 FR 12541, Mar. 25, 1983, as amended at 51 FR 41338, Nov. 14, 1986; 58 FR 30666, 30667, May 26, 1993; 62 FR 46025, Aug. 29, 1997; 63 FR 26307, May 12, 1998; 64 FR 41681, July 30, 1999; 68 FR 50584, Aug. 22, 2003; 72 FR 43436, Aug. 3, 2007; 82 FR 36633, Aug. 4, 2017; 84 FR 38832, Aug. 7, 2019]
Notes of Decisions
Cited in 18 cases (4 in the last 5 years), 1985–2023 · leading case: Jeffrey Bonkowski v. Oberg Industries Inc
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Jeffrey Bonkowski v. Oberg Industries Inc (2015) ca3 · cites it 2× “at 104 (quoting 42 C.F.R. 409.30(a)(1)), and another rule providing that “‘a patient is considered an inpatient if [he or she] is formally admitted as [an] inpatient,’” id.”
Rapport v. Leavitt (2008) nywd · cites it 9× “See 42 C.F.R. § 409.30 (a). Accordingly, it is a requirement for MA organizations to provide coverage of post-hospital extended care services at a SNF where a beneficiary has met the three-day qualifying hospital stay requirement provided other requirements for Medicare coverage…”
Barrows v. Becerra (2022) ca2 “Leyanna should have been classified as an inpatient, she did not demonstrate that the injury she suffered by not having her SNF care covered under Part A can be attributed to the classification error as opposed to the possibility that the SNF care was not “reasonable and…”
Estate of Landers Ex Rel. Landers v. Leavitt (2008) ca2 “” 42 C.F.R. § 409.30 (a)(1). And according to another rule, “a patient is considered an inpatient if [he or she is] formally admitted as [an] inpatient.”
United States ex rel. Johnson v. Golden Gate National Senior Care, L.L.C. (2016) mnd “42 C.F.R. §§ 409.30 , 409.31; Medicare Benefit Policy Manual, Ch.”
Gartmann v. Secretary of United States Department of Health & Human Services (1986) nyed “42 C.F.R. §§ 409.30 -.36 further define the requirements of post-hospital extended care covered by the Act.”
Jenkel v. Shalala (1994) ctd “” 42 C.F.R. § 409.30 (a). Plaintiff arrived at Waterbury Hospital on June 11, 1988.”
Roth v. Secretary of Health and Human Services (1985) nywd “42 C.F.R. §§ 409.30 , 409.31(a). A skilled service is one which is “so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel.”
Landa Ex Rel. Landa v. Shalala (1995) nyed · cites it 3× “See 42 C.F.R. 409.30(b) (providing that to qualify for extended care coverage, the patient must have needed and received skilled care within 30 calendar days after the date of discharge •from the hospital).”
Walsh v. Secretary of United States Department of Health & Human Services (1986) nyed “Any expenses incurred for items or services which are not “reasonable and necessary” for diagnosis or treatment are specifically excluded from coverage under the Act, as are expenses for “custodial care,” which is defined in the regulations promulgated under Title XVIII as “any…”
Goodrich v. Heckler (1986) ctd “See 42 C.F.R. §§ 409.30 and 409.31. While the need for insulin is a factor in determining such entitlement, it alone is not determinative.”
United Healthcare Insurance v. Sebelius (2011) mnd · cites it 3× “42 C.F.R. § 409.30 . However, an MA plan may elect to provide coverage of posthospital SNF care without requiring a prior hospital stay.”
Show all 18 citing cases →
— 42 C.F.R. § 409.30(a)(1) — 1 case
Jeffrey Bonkowski v. Oberg Industries Inc (2015) ca3 “at 104 (quoting 42 C.F.R. 409.30(a)(1)), and another rule providing that “‘a patient is considered an inpatient if [he or she] is formally admitted as [an] inpatient,’” id.”
— 42 C.F.R. § 409.30(b) — 1 case
Landa Ex Rel. Landa v. Shalala (1995) nyed “See 42 C.F.R. 409.30(b) (providing that to qualify for extended care coverage, the patient must have needed and received skilled care within 30 calendar days after the date of discharge •from the hospital).”
— 42 C.F.R. § 409.30(b)(2) — 1 case
Landa Ex Rel. Landa v. Shalala (1995) nyed “See 42 C.F.R. 409.30(b) (providing that to qualify for extended care coverage, the patient must have needed and received skilled care within 30 calendar days after the date of discharge •from the hospital).”
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