In this case, the court considered this issue: Does the phrase “entitled… to benefits” include all who meet basic program eligibility criteria, whether or not benefits are actually received?
The case was decided on April 29, 2025.
In this case, a group of over 200 hospitals claimed that the Department of Health and Human Services (HHS) miscalculated their Disproportionate Share Hospital (DSH) adjustments, which provide additional funding to hospitals treating a high percentage of low-income patients. The dispute centered on the interpretation of the phrase "entitled to supplementary security income (SSI) benefits" under subchapter XVI. The hospitals argued that this phrase should include all patients enrolled in the SSI system at the time of hospitalization, even if they were not entitled to an SSI payment during that month. HHS, however, interpreted it to mean patients who were eligible to receive an SSI payment during the month of hospitalization.
The Provider Reimbursement Review Board denied the hospitals' request for additional reimbursement on procedural grounds, and the Centers for Medicare & Medicaid Services denied relief on the merits. The District Court rejected the hospitals' claims and granted summary judgment to HHS. The D-C Circuit affirmed, concluding that SSI benefits are about cash payments for needy individuals and that it makes little sense to say individuals are entitled to the benefit in months when they are not eligible for a payment.
The Supreme Court of the United States held that an individual is "entitled to SSI benefits" for purposes of the Medicare fraction when she is eligible to receive an SSI cash payment during the month of her hospitalization. The Court reasoned that SSI benefits are cash benefits determined on a monthly basis, and eligibility for such benefits is also determined monthly. The Court affirmed the judgment of the D-C Circuit, respecting the specific formula that Congress prescribed for calculating the Medicare fraction.
The opinion is presented here in its entirety, but with citations omitted. If you appreciate this episode, please subscribe. Thank you.
