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. § 409.31

Level of care requirement

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(a) Definition. As used in this section, skilled nursing and skilled rehabilitation services means services that:

(1) Are ordered by a physician;

(2) Require the skills of technical or professional personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and

(3) Are furnished directly by, or under the supervision of, such personnel.

(b) Specific conditions for meeting level of care requirements. (1) The beneficiary must require skilled nursing or skilled rehabilitation services, or both, on a daily basis.

(2) Those services must be furnished for a condition—

(i) For which the beneficiary received inpatient hospital or inpatient CAH services; or

(ii) Which arose while the beneficiary was receiving care in a SNF or swing-bed hospital for a condition for which he or she received inpatient hospital or inpatient CAH services; or

(iii) For which, for an M + C enrollee described in § 409.20(c)(4), a physician has determined that a direct admission to a SNF without an inpatient hospital or inpatient CAH stay would be medically appropriate.

(3) The daily skilled services must be ones that, as a practical matter, can only be provided in a SNF, on an inpatient basis.

[48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993; 68 FR 50854, Aug. 22, 2003; 70 FR 45055, Aug. 4, 2005]
Notes of Decisions
Cited in 35 cases (4 in the last 5 years), 1984–2023 · leading case: Est. of Martha S. French v. Stratford House, 333 S.W.3d 546 (Tenn. 2011).
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Est. of Martha S. French v. Stratford House, 333 S.W.3d 546 (Tenn. 2011). “See 42 C.F.R. §§ 409.31 (a)(3), 409.32(a) (2009).”
Rapport v. Leavitt, 564 F. Supp. 2d 186 (W.D.N.Y. 2008). · cites it 6× “See 42 C.F.R. § 409.31 (b)(2)(iii). ADMINISTRATIVE APPEALS PROCESS The Medicare regulations provide for administrative review of a denial of a Part C claim, and then federal court review of the Secretary’s final decision.”
Troutman v. Cohen, 588 F. Supp. 590 (E.D. Pa. 1984). · cites it 3× “42 C.F.R. § 409.31 (1983). They also provide examples of nursing services which qualify as skilled nursing services.”
United States ex rel. Martin v. Life Care Centers of Am., Inc., 114 F. Supp. 3d 549 (E.D. Tenn. 2014). · cites it 2× “§ 1395f(a)(2)(B); 42 C.F.R. § 409.31 (b). Additionally, Medicare does not cover services' that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member[.”
United States ex rel. Johnson v. Golden Gate Nat'l Senior Care, L.L.C., 223 F. Supp. 3d 882 (D. Minnesota 2016). “42 C.F.R. §§ 409.31 , 410.59, 410.60. A nursing home licensed to provide skilled services, such as Hillcrest, is a *889 “skilled nursing facility” or “SNF.”
Fox v. Bowen, 656 F. Supp. 1236 (D. Conn. 1987). · cites it 2× “” 42 C.F.R. § 409.31 (a)(3) (emphasis supplied).”
George FRIEDMAN, Plaintiff-Appellant, v. Sec'y OF the Dep't OF HEALTH & HUMAN Servs., Defendant-Appellee, 819 F.2d 42 (2d Cir. 1987). “42 C.F.R. § 409.31 . See also 42 C.F.R. § 409.”
Child.'s Healthcare is a Legal Duty, Inc. v. Min De Parle, 212 F.3d 1084 (8th Cir. 2000). · cites it 2× “See 42 C.F.R. 409.31. Further, the regulations of “skilled nursing facilities” provide that, to be considered a skilled service, it “must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical…”
Hirsch v. Bowen, 655 F. Supp. 342 (S.D.N.Y. 1987). · cites it 3× “33 (d) rather than “skilled care”, 42 C.F.R. § 409.31.33 ; 2) Hirsch’s nursing home care was not for a condition for which he had received inpatient treatment, 42 C.”
Matthews v. Leavitt, 452 F.3d 145 (2d Cir. 2006). “See 42 C.F.R. § 409.31 (defining skilled nursing and skilled rehabilitation services).”
Maryland Dep't of Health & Mental Hygiene v. Brown, 935 A.2d 1128 (Md. Ct. Spec. App. 2007). “” 42 C.F.R. § 409.31 (a)(2)-(3) in turn defines “skilled services” as those that “[r]equire the skills of technical or professional personnel such as registered nurses [or] licensed practical (vocational) nurses .”
Hurley v. Bowen, 674 F. Supp. 421 (E.D.N.Y 1987). · cites it 3× “42 C.F.R. § 409.31 (a). The services must also be (1) necessary on a daily basis, (2) for a condition which was treated in a hospital, and (3) those which, “as a practical matter, can only be provided in a skilled nursing facility.”
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— 42 C.F.R. § 409.31(a) — 2 cases
Brae Loch Manor Health Care Facility v. Thompson, 287 F. Supp. 2d 191 (W.D.N.Y. 2003).
Brae Loch Manor Health Care Facility v. Thompson, 287 F. Supp. 2d 191 (W.D.N.Y. 2003).
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