Becerra v. Empire Health Foundation, For Valley Hospital Medical Center

Summary

For purposes of calculating the Medicare fraction—one of two fractions the Medicare program uses to adjust the rates paid to hospitals that serve a higher-than-usual percentage of low-income patients—those individuals “entitled to [Medicare Part A] benefits” are all those qualifying for the program, regardless of whether they receive Medicare payments for part or all of a hospital stay.

Text

PRELIMINARY PRINT 
Volume 597 U. S. Part 1 
Pages 424–449 
OFFICIAL REPORTS 
OF 
THE SUPREME COURT 
June 24, 2022 
REBECCA A. WOMELDORF 
reporter of decisions 
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424 OCTOBER TERM, 2021 
Syllabus 
BECERRA, SECRETARY OF HEALTH AND HUMAN 
SERVICES v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
certiorari to the united states court of appeals for 
the ninth circuit 
No. 20–1312. Argued November 29, 2021—Decided June 24, 2022 
Once a person turns 65 or has received federal disability benefts for 24 
months, he becomes “entitled” to benefts under Part A of Medicare. 
42 U. S. C. §§ 426(a)–(b). Part A provides coverage for, among other 
things, inpatient hospital treatment. See § 1395d(a). Medicare pays 
hospitals a fxed rate for such treatment based on the patient's diagnosis, 
regardless of the hospital's actual cost and subject to certain adjust-
ments. §§ 1395ww(d)(1)–(5). One such adjustment is the “dispropor-
tionate share hospital” (DSH) adjustment, which provides higher-than-
usual rates to hospitals that serve a higher-than-usual percentage of 
low-income patients. To calculate the DSH adjustment, the Depart-
ment of Health and Human Services (HHS) adds together two statuto-
rily described fractions: the Medicare fraction—which represents the 
proportion of a hospital's Medicare patients who have low incomes—and 
the Medicaid fraction—which represents the proportion of a hospital's 
total patients who are not entitled to Medicare and have low incomes. 
Together those fractions produce the “disproportionate-patient percent-
age,” which determines whether a hospital will receive a DSH adjust-
ment, and how large it will be. 
Not all patients who qualify for Medicare Part A have their hospital 
treatment paid for by the program. Non-payment may occur, for exam-
ple, if a patient's stay exceeds Medicare's 90-day cap per spell of illness, 
see § 1395d, or if a patient is covered by a private insurance plan, see 
§ 1395y(b)(2)(A). Such limits on Medicare's coverage prompt the ques-
tion raised here: whether patients whom Medicare insures but does not 
pay for on a given day are patients “who (for such days) were entitled 
to [Medicare Part A] benefts” for purposes of computing a hospital's 
disproportionate-patient percentage. § 1395ww(d)(5)(F)(vi)(I). 
A 2004 HHS regulation says yes: If the patient meets the basic statu-
tory criteria for Medicare (i. e., is over 65 or disabled), then the patient 
counts in the denominator and, if poor, in the numerator of the Medicare 
fraction. See 69 Fed. Reg. 49098–49099. Respondent Empire Health 
Foundation challenged that regulation as inconsistent with the statute. 
The Ninth Circuit agreed. That court focused on the statute's use of

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Syllabus 
two different phrases: “entitled to [Medicare Part A] benefts” and “eli-
gible for [Medicaid] assistance.” The Ninth Circuit read the latter 
phrase to mean that a patient qualifes for Medicaid and the former 
phrase to mean that a patient has an absolute right to payment from 
Medicare. The Court granted certiorari to resolve a confict between 
the Ninth Circuit and two other Circuit Courts, which had approved of 
HHS's regulation. 
Held: In calculating the Medicare fraction, individuals “entitled to [Medi-
care Part A] benefts” are all those qualifying for the program, regard-
less of whether they receive Medicare payments for part or all of a 
hospital stay. Pp. 434–445. 
HHS's regulation is consistent with the text, context, and structure 
of the DSH provisions. The agency has interpreted the phrase “enti-
tled to benefts” in those provisions to mean just what it means through-
out the Medicare statute: qualifying for benefts. And counting every-
one who qualifes for Medicare benefts in the Medicare fraction—and 
no one who qualifes for those benefts in the Medicaid fraction—accords 
with the statute's attempt to capture, through two separate measure-
ments, two different segments of a hospital's low-income patient 
population. 
(a) Empire's textual argument has a two-part structure. Echoing 
the Ninth Circuit, Empire primarily contends that the words “entitled” 
and “eligible” have different meanings. According to Empire, to be “el-
igible” for a beneft is to be “qualifed” to seek it; to be “entitled” to a 
beneft means instead to have an “absolute right” to its payment. But 
throughout the Medicare statute, “entitled to benefts” is essentially a 
term of art meaning “qualifying for benefts,” i. e., being over 65 or 
disabled. And in the end, Empire basically concedes that point. It 
must devise a way to give “entitled to benefts” a different meaning in 
the fraction descriptions than everywhere else in the Medicare statute. 
So Empire shifts gears, relying now on the parenthetical phrase “(for 
such days)” to transform the usual statutory meaning of “entitled to 
benefts” to something different and novel. But those three little words 
do not accomplish what Empire would like, having the much less radical 
function of excluding days of a patient's hospital stay before he qualifes 
for Medicare (e. g., turns 65). Pp. 434–441. 
(1) The Medicare statute explicitly states that “[e]very individual” 
who “has attained age 65” and is entitled to ordinary social security 
payments and “every individual” under age 65 who has been entitled to 
federal disability benefts for at least 24 months “shall be entitled to” 
Medicare Part A benefts. §§ 426(a)–(b). This broad meaning of “enti-
tlement” coexists with limitations on payment. The entitlement to ben-

426 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Syllabus 
efts, the statute repeatedly says, is an entitlement to payment under 
specifed conditions. So a person remains entitled to benefts even if he 
has run into one of the statute's conditions, such as the 90-day cap on 
inpatient hospital services. For example, the statute twice refers to 
patients who are “entitled to benefts under part A but ha[ve] exhausted 
benefts for inpatient hospital services.” §§ 1395l(a)(8)(B)(i), 1395l(t)(1) 
(B)(ii). In thus describing the Part A entitlement, the statute refects 
the complexity of health insurance: An insured who hits some limit on 
coverage for, say, eye care is still insured. His policy will pay for more 
eye care in the next coverage period and meanwhile will pay for his 
knee replacement. 
If “entitled to benefts” instead bore Empire's meaning, Medicare ben-
efciaries would lose important rights and protections, such as the ability 
to enroll in other Medicare programs. See §§ 1395o(a), 1395w-21(a)(3), 
1395w–101(a)(3)(A). Empire's interpretation would also make a hash of 
provisions designed to inform Medicare benefciaries of their benefts, 
see § 1395b–2(a), and to protect benefciaries from misleading marketing 
materials, see § 1395w–21(a)(3). Congress could not have intended to 
write a statute whose safeguards would apply or not apply, or fuctuate 
constantly, based on the happenstance of whether Medicare paid for hos-
pital care on a given day. Pp. 435–439. 
(2) Empire concedes that its interpretation cannot be applied 
throughout the Medicare statute. To get around this, Empire claims 
that the parenthetical in “patients who (for such days) were entitled to 
[Part A] benefts,” § 1395ww(d)(5)(F)(vi)(I), converts the usual statutory 
meaning of “entitled to benefts” to something different: actually receiv-
ing payment. That slight phrase, however, cannot bear so much inter-
pretive weight. Instead, the parenthetical works as HHS says: hand in 
hand with the ordinary statutory meaning of “entitled to benefts.” It 
directs HHS to count only those individuals who qualify for Medicare 
on a particular day. So if a patient turns 65 on the 15th day of a 30-
day hospital stay, HHS will count only 15 days. Pp. 439–441. 
(b) The structure of the relevant statutory provisions reinforces the 
conclusion that “entitled to benefts” means qualifying for benefts. The 
statute recompenses hospitals for serving two different low-income pop-
ulations: low-income Medicare patients and low-income non-Medicare 
patients. HHS's reading of “entitled” comports with this structure: a 
low-income Medicare patient always count in the Medicare fraction. 
That is so regardless of whether the Medicare program is actually pay-
ing for a day of his care—because that fact has no relationship to his 
fnancial status. Empire's interpretation, by contrast, fts poorly with 
the statutory structure. Its who-paid-for-a-day-of-care test has no rela-
tionship to a patient's fnancial status. So on Empire's view, a patient 
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Syllabus 
could phase in and out of the Medicare fraction regardless of income. 
Empire responds by asserting that any low-income person excluded 
from the Medicare fraction (say, because of exhaustion of benefts) would 
get counted instead in the Medicaid fraction. But even if that is true, 
Empire's scheme would result in patients ping-ponging back and forth 
between the two fractions based on the happenstance of actual Medicare 
payments. In any event, Empire is too quick to claim that those who 
(on its view) are tossed from the Medicare fraction for non-income-based 
reasons like exhaustion of benefts would still wind up in the Medicaid 
fraction. Applying Empire's reading of “for such days,” a low-income 
patient who has exhausted his coverage would not get counted at all, in 
either fraction, but he would remain just as low-income and impose just 
as high costs on the hospital treating him. Empire's only response is 
to insist that its interpretation must be right because it usually (though 
not always) leads to higher DSH payments. But the point of the stat-
ute is not to pay hospitals the most money possible; it is to compensate 
them for serving a disproportionate share of low-income patients. 
Pp. 442–445. 
958 F. 3d 873, reversed and remanded. 
Kagan, J., delivered the opinion of the Court, in which Thomas, 
Breyer, Sotomayor, and Barrett, JJ., joined. Kavanaugh, J., fled a 
dissenting opinion, in which Roberts, C. J., and Alito and Gorsuch, JJ., 
joined, post, p. 445. 
Jonathan C. Bond argued the cause for petitioner. With 
him on the briefs were Solicitor General Prelogar, Acting 
Solicitor General Fletcher, Acting Assistant Solicitor Gen-
eral Boynton, Deputy Solicitor General Kneedler, Mark B. 
Stern, and Stephanie R. Marcus. 
Daniel J. Hettich argued the cause for respondent. With 
him on the brief were Ashley C. Parrish, Jeffrey S. Bucholtz, 
Anne M. Voigts, and Matthew V. H. Noller.* 
*Michael Pepson and Cynthia Fleming Crawford filed a brief for 
the Americans for Prosperity Foundation as amicus curiae urging 
reversal. 
Briefs of amici curiae urging affrmance were fled for Certain Hospi-
tals et al. by David A. Hickerson; and for the Federation of American 
Hospitals by Kelly A. Carroll.

428 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
Justice Kagan delivered the opinion of the Court. 
The Medicare program reimburses hospitals at higher -
than-usual rates when they serve a higher-than-usual per-
centage of low-income patients. The enhanced rates are cal-
culated by adding together two fractions, called the Medicare 
fraction and the Medicaid fraction. Roughly speaking, the 
former measures the hospital's low-income senior-citizen 
population, and the latter the hospital's low-income non-
senior population. 
This case raises a technical but important question about 
the Medicare fraction. The statutory description of that 
fraction refers to “the number of [a] hospital's patient days” 
attributable to low-income patients “who (for such days) 
were entitled to benefts under part A of [Medicare].” 42 
U. S. C. § 1395ww(d)(5)(F)(vi)(I). According to the Depart-
ment of Health and Human Services (HHS), a person is “enti-
tled to [Part A] benefts” under the statute if he qualifes for 
the Medicare program—essentially, if he is over 65 or dis-
abled. That remains so even when Medicare is not paying 
for part or all of his hospital stay—for example, because a 
private insurer is legally responsible or because he has used 
up his allotted coverage. Today, we approve HHS's under-
standing of the Medicare fraction. 
I 
The Medicare program provides Government-funded 
health insurance to over 64 million elderly or disabled 
Americans. (The vast majority of that number are senior 
citizens.) When a person turns 65 or has received federal 
disability benefts for 24 months, he automatically (i. e., with-
out application or other fling) becomes “entitled” to benefts 
under Medicare Part A. §§ 426(a)–(b). The most signif-
cant Part A beneft is coverage for inpatient hospital treat-
ment; Part A also covers associated physician and skilled 
nursing services. See § 1395d(a); HHS, CMS Ruling No. 
CMS–1498–R, p. 10 (Apr. 28, 2010), https://www.cms.gov / 
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Opinion of the Court 
regulations-and-guidance/guidance/rulings/downloads/ 
cms1498r.pdf (CMS–1498–R). In addition, entitlement to 
Part A generally enables a patient to enroll (if he wishes) in 
Medicare's other programs: Part B's coverage for outpatient 
care; Part C's coverage through privately administered 
Medicare Advantage plans; and Part D's coverage for pre-
scription drugs. See §§ 1395o(a)(1), 1395w–21(a)(3), 1395w– 
101(a)(3)(A). 
The Medicare program pays a hospital a fixed rate 
for treating each Medicare patient, based on the patient's 
diagnosis and regardless of the hospital's actual costs. 
§§ 1395ww(d)(1)–(4). The rates are designed to refect the 
amounts an efficiently run hospital, in the same region, 
would expend to treat a patient with the same diagnosis. 
See 42 CFR § 412.2 (2022). If the hospital spends anything 
more, it suffers a fnancial loss. The fat-rate payment sys-
tem thus gives hospitals an incentive to provide effcient 
levels of medical service. 
But Congress, recognizing complexity in healthcare, pro-
vided for various hospital-specifc rate adjustments—includ-
ing the one at issue here for treating low-income patients. 
The “disproportionate share hospital” (DSH) adjustment 
gives hospitals serving an “unusually high percentage of low-
income patients” enhanced Medicare payments. Sebelius v. 
Auburn Regional Medical Center , 568 U. S. 145, 150 (2013). 
The mark-up refects that low-income individuals are often 
more expensive to treat than higher income ones, even for 
the same medical conditions. In compensating for that dis-
parity, the DSH adjustment encourages hospitals to treat 
low-income patients. 
To calculate a hospital's DSH adjustment, HHS adds to-
gether two statutorily described fractions, usually called the 
Medicare fraction and the Medicaid fraction. Those frac-
tions are designed to capture two different low-income popu-
lations that a hospital serves. The Medicare fraction repre-
sents the proportion of a hospital's Medicare patients who 
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430 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
have low incomes, as identifed by their entitlement to sup-
plementary security income (SSI) benefts. SSI is a “wel-
fare program” providing benefts to “fnancially needy indi-
viduals” who (like Medicare patients generally) are over 65 
or disabled. Bowen v. Galbreath, 485 U. S. 74, 75 (1988); see 
§§ 1382(a)(1), 1382c(a)(1). The Medicaid fraction represents 
the proportion of a hospital's patients who are not entitled 
to Medicare and have low incomes, as identifed by their 
eligibility for Medicaid. The Medicaid program provides 
health insurance to all low-income individuals, regardless of 
age or disability. See § 1396d(a). So at a high level of gen-
erality, the Medicare fraction is a measure of a hospital's se-
nior (or disabled) low-income population, while the Medicaid 
fraction is a measure of a hospital's non-senior (except for 
disabled) low-income population. 
With that under your belt, you might be ready to absorb 
the relevant statutory language (but don't bet on it). The 
Medicare fraction is described as: 
“[a] fraction (expressed as a percentage), the numerator 
of which is the number of [a] hospital's patient days for 
[the fscal year] which were made up of patients who 
(for such days) were entitled to benefts under part A of 
[Medicare] and were entitled to [SSI] benefts[ ], and the 
denominator of which is the number of such hospital's 
patient days for such fscal year which were made up of 
patients who (for such days) were entitled to benefts 
under [Medicare] part A.” § 1395ww(d)(5)(F)(vi)(I). 
That is a mouthful (and without the brackets, it's even 
worse). So again, in general terms: The numerator is the 
number of patient days attributable to Medicare patients 
who are poor. The denominator is the number of patient 
days attributable to all Medicare patients. Divide the for-
mer by the latter to get the fraction “expressed as a percent-
age.” Ibid. 
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And similarly for the Medicaid fraction. That fraction is 
described as: 
“[a] fraction (expressed as a percentage), the numerator 
of which is the number of [a] hospital's patient days for 
[the fscal year] which consist of patients who (for such 
days) were eligible for medical assistance under [Medic-
aid], but who were not entitled to benefts under part A 
of [Medicare], and the denominator of which is the total 
number of the hospital's patient days for such [fscal 
year].” § 1395ww(d)(5)(F)(vi)(II). 
That too is a lot to digest. So again, in general terms: The 
numerator is the number of patient days attributable to non-
Medicare patients who are poor. The denominator is the 
total number of patient days. Divide the former by the 
latter to get the second percentage the DSH calculation 
requires.
1 
Once both percentages have been calculated, they are 
added together to produce the “disproportionate-patient per-
centage.” That percentage determines whether a hospital 
will receive a DSH adjustment, and if so, how large it will 
be. The combined percentage must usually equal or ex-
ceed 15% for a hospital to get an adjustment. See 
§ 1395ww(d)(5)(F)(v). So, for example, if a hospital's Medi-
1 You may have noticed that the denominator of the Medicare fraction 
(the number of patient days attributable to Medicare patients) is smaller 
than the denominator of the Medicaid fraction (the total number of patient 
days). That means each low-income patient day included in the Medicare 
fraction will count for more than each low-income patient day included in 
the Medicaid fraction. So, to use an overly simplifed example, a hospital 
with 100 of the former will get a larger rate adjustment than a hospital 
with 100 of the latter. Although Congress did not explain that difference, 
it presumably refects the Medicare-centric perspective of what is, after 
all, a Medicare payment scheme. (The Medicaid statute separately re-
quires States to make DSH payments, using a different formula that fo-
cuses on a hospital's Medicaid population. See 42 U. S. C. § 1396r–4. But 
that statutory provision is not at issue here.) 
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432 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
care fraction is 10% and its Medicaid fraction is 5%, then the 
hospital would qualify for increased rates. The higher the 
disproportionate-patient percentage goes, the greater the 
rate mark-up that the hospital will receive. §§ 1395ww(d) 
(5)(F)(vii)–(xiv). 
This case is about how to count patients who qualify for 
Medicare Part A—because they are over 65 or disabled— 
at times when the program is not paying for their hospital 
treatment. Such non-payment may occur for a number of 
reasons. For one, Medicare usually pays for only the frst 
90 days of a hospital stay associated with a single “spell of 
illness.” See § 1395d; 42 CFR § 409.61(a). If a patient's 
stay for an illness exceeds that limit, his coverage is “ex-
hausted.” § 409.61(a). For another, Medicare pays for hos-
pital treatment only once a patient has used up other medical 
insurance. See § 1395y(b)(2)(A). So if a patient has a pri-
vate insurance plan, or is injured by a tortfeasor with insur-
ance, Medicare will not pay unless and until that other policy 
runs dry. Limits like those prompt the question presented 
here: Are patients whom Medicare insures but does not pay 
for on a given day “entitled to [Medicare Part A] benefts,” 
for purposes of computing a hospital's disproportionate-
patient percentage? §§ 1395ww(d)(5)(F)(vi)(I–II). 
An HHS regulation, issued in 2004, says those patients 
remain so entitled. See 69 Fed. Reg. 48916. Under the 
regulation, whether Medicare is actually paying for a pa-
tient's hospital treatment is irrelevant. So, for example, it 
does not matter that a patient has exhausted his 90 days of 
coverage for an illness, or that a private insurer is paying 
for his hospital stay. As long as the patient meets the basic 
statutory criteria for Medicare (i. e., he is over 65 or dis-
abled), then the patient counts in the denominator and, if he 
is poor, in the numerator of the Medicare fraction (as “enti-
tled to [Medicare Part A] benefts”). See id., at 49098– 
49099. And by the same token, he does not count in the 
numerator of the Medicaid fraction (which includes only

Cite as: 597 U. S. 424 (2022) 433 
Opinion of the Court 
those “not entitled to [Medicare Part A] benefts”). See 
ibid. As HHS explained in 2004, the effect of the regulation 
varies depending on the makeup of a hospital's patient popu-
lation. See ibid. But for most hospitals, the regulation has 
worked to decrease DSH payments, because as benefciaries 
are added to the Medicare fraction's denominator (even 
though poor benefciaries are also added to its numerator), a 
hospital's Medicare fraction generally (though not always) 
goes down. See Letter from E. Prelogar, Solicitor General, 
to S. Harris, Clerk of Court (Nov. 23, 2021). 
Respondent Empire Health Foundation challenged the 
regulation as inconsistent with the statutory fraction de-
scriptions, and the Court of Appeals for the Ninth Circuit 
agreed. See Empire Health Foundation v. Azar, 958 F. 3d 
873 (2020). The court focused on the statute's use of two 
different phrases: “entitled to [Medicare Part A] benefts” 
and (in the Medicaid fraction alone) “eligible for [Medicaid] 
assistance.” Id., at 885. Relying on Circuit precedent, the 
court read the latter, “eligible” phrase to “mean that a pa-
tient simply meets the Medicaid statutory criteria”—regard-
less of whether “Medicaid actually paid” for a given service 
on a given day. Ibid. That approach, of course, is analo-
gous to the one the HHS regulation adopts for Medicare 
benefciaries. But the Ninth Circuit reasoned that the stat-
utory language relating to Medicare is different: It asks 
whether a person is “entitled to” (not “eligible for”) benefts. 
And the word “entitled,” the court held (relying on the same 
precedent), “mean[s] that a patient has an `absolute right . . . 
to payment.' ” Ibid. (ellipsis in original). So even if a pa-
tient is over 65, he is not “entitled to [Medicare Part A] bene-
fts” within the meaning of the statute for any hospital stay, 
or part thereof, Medicare is not paying for. 
As the Ninth Circuit recognized, two other Courts of Ap-
peals had deferred to HHS's contrary view of the statute and 
upheld the regulation. See Metropolitan Hospital v. De-
partment of Health and Human Servs., 712 F. 3d 248 (CA6 
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434 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
2013); Catholic Health Initiatives Iowa Corp. v. Sebelius, 
718 F. 3d 914 (CADC 2013). We granted certiorari to re-
solve the confict. See 594 U. S. ––– (2021). 2 
II 
HHS's regulation correctly construes the statutory lan-
guage at issue. The ordinary meaning of the fraction de-
scriptions, as is obvious to any ordinary reader, does not 
exactly leap off the page. See Catholic Health Initiatives, 
718 F. 3d, at 916 (The “language is downright byzantine”). 
The provisions are technical: They call to mind Justice 
Frankfurter's injunction that when a statute is “addressed 
to specialists, [it] must be read by judges with the minds of 
the specialists.” Some Refections on the Reading of Stat-
utes, 47 Colum. L. Rev. 527, 536 (1947). But when read in 
that suitable way, the fraction descriptions disclose a surpris-
ingly clear meaning—the one chosen by HHS. The text and 
context support the agency's reading: HHS has interpreted 
the words in those provisions to mean just what they mean 
throughout the Medicare statute. And so too the structure 
of the DSH provisions supports HHS: Counting everyone 
who qualifes for Medicare benefts in the Medicare frac-
tion—and no one who qualifes for those benefts in the Med-
icaid fraction—accords with the statute's attempt to capture, 
through two separate measurements, two different segments 
of a hospital's low-income patient population. 
A 
Speaking of twos, Empire's textual argument also has a 
bifurcated structure—but neither part can produce its de-
sired result. Empire primarily contends, echoing the Ninth 
Circuit, that “different words [mean] different things” when 
2 This case does not raise the question whether HHS has properly inter-
preted the phrase “entitled to [SSI] benefts” in the Medicare fraction. 
Accordingly, we express no view on that issue. 
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Opinion of the Court 
used in a single statute—and so “entitled” means something 
different from “eligible.” Brief for Respondent 22. To be 
“eligible” for a beneft, Empire says, is to be “qualifed” to 
seek it; to be “entitled” to a beneft means instead to have 
an “absolute right” to its payment. Id., at 4, 30. But that 
reading, even if plausible in the abstract, does not work in 
the Medicare statute. There, “entitled to benefts” is essen-
tially a term of art, used over and over to mean qualifying 
(or, yes, being eligible) for benefts—i. e., being over 65 or 
disabled. And in the end, Empire basically concedes that 
point. It must devise a way to give “entitled to benefts” a 
different meaning in the fraction descriptions than the 
phrase has everywhere else in the Medicare law. See Tr. of 
Oral Arg. 37–41. So Empire shifts gears, relying now on 
the parenthetical phrase “(for such days)” to do its work—to 
transform the usual statutory meaning of “entitled to bene-
fts” to something different and novel. See ibid.; § 1395ww 
(d)(5)(F)(vi)(I) (“patients who (for such days) were entitled to 
[Medicare Part A] benefts”). (The dissent, for its part, fo-
cuses most of its energies on this latter stage of Empire's 
argument.) But those three little words do not accomplish 
what Empire would like, having the much less radical func-
tion of excluding days of a patient's hospital stay before he 
qualifes for Medicare (e. g., turns 65). So contrary to Em-
pire's claim, being “entitled” to Medicare benefts still 
means—in the fraction descriptions, as throughout the stat-
ute—meeting the basic statutory criteria, not actually re-
ceiving payment for a given day's treatment. 
1 
First and foremost, the Medicare statute explicitly identi-
fes which individuals are “entitled to hospital insurance ben-
efts under part A”—all people who meet the basic statutory 
criteria. §§ 426(a)–(b). “Every individual,” the law states, 
who “has attained age 65” and is entitled to ordinary social 
security payments “shall be entitled to” Medicare Part A

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436 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
benefts. § 426(a). So too, “every individual” under age 65 
who has been entitled to federal disability benefts for at 
least 24 months “shall be entitled” to Medicare Part A bene-
fts. § 426(b). The “[e]ntitlement to hospital insurance ben-
efts” (as the section caption reads) is “automatic”: Age or 
disability makes a person “entitled” to Part A benefts with-
out an application or anything more. § 426; Hall v. Sebelius, 
667 F. 3d 1293, 1294–1296 (CADC 2012). Turn 65 or receive 
disability benefts for 24 months, and you have an entitle-
ment to Part A benefts—because the latter is, according to 
the statute, simply a legal status arising from the former.
3 
That broad meaning of “entitlement” coexists with limi-
tations on payment, as several statutory provisions show. 
The entitlement to benefts, the statute repeatedly says, is 
an entitlement to payment under specifed conditions. To 
quote one provision: “entitlement of an individual” to Medi-
care Part A benefts “consist[s] of entitlement to have pay-
ment made under, and subject to the limitations in, part A.” 
§ 426(c)(1); see § 1395d(a) (similarly stating that the entitle-
ment to benefts entails the receipt of “payment[s] . . . subject 
to the provisions of this part”). Those limits on payment 
include, as described earlier, the 90-day hospital-stay cap. 
See supra, at 432. And indeed the statute twice refers 
to patients who are “entitled to benefts under part A but 
3 Another way of putting the point is to say that the Medicare statute 
uses the term “entitled” to benefts in the same way as the Medicaid stat-
ute uses the term “eligible” for benefts. Compare 42 U. S. C. § 426 (“enti-
tled” in Medicare context) with, e. g., §§ 1396, 1396d (“eligible” in Medicaid 
context). That difference in overall statutory terminology is mirrored in 
the fraction provisions—“entitled to [Medicare Part A] benefts” and “eli-
gible for [Medicaid] assistance.” §§ 1395ww(d)(5)(F)(vi)(I–II). As the 
D. C. Circuit put the point: “Congress has, throughout the various Medi-
care and Medicaid statutory provisions, consistently used the words `eligi-
ble' to refer to potential Medicaid benefciaries and `entitled' to refer to 
potential Medicare benefciaries.” Northeast Hospital Corp. v. Sebelius, 
657 F. 3d 1, 12 (2011). Congress simply followed suit when referring to 
the two programs in the fraction provisions.

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ha[ve] exhausted benefts for inpatient hospital services.” 
§§ 1395l(a)(8)(B)(i), 1395l(t)(1)(B)(ii). Under Empire's read-
ing, that statement makes no sense: A patient is not, Empire 
argues, “entitled to benefts” when the statute precludes 
payment. See supra, at 434–435. But the statute says oth-
erwise. It considers those who have exhausted their cover-
age (and so cannot receive further payments for a hospital 
stay) still “entitled to [Part A] benefts.” 
In thus describing the Part A entitlement, the Medicare 
statute refects the complexity of health insurance. Con-
sider your own health plan (maybe it is Medicare). You 
might have hit some limit on coverage as to one medical 
service—let's say, eye care. But you're still insured: Your 
policy will pay for more eye care in the next coverage period 
and meanwhile will pay for your knee replacement. So it 
is with Medicare Part A. As the 2004 regulation explains, 
patients “who have exhausted their Medicare Part A inpa-
tient coverage may still be entitled to other Part A benefts.” 
69 Fed. Reg. 49098. Medicare Part A also covers, “for ex-
ample, certain physician services and skilled nursing serv-
ices” outside the hospital setting. See CMS–1498–R, at 10. 
And even as to hospital care, another 90 days of coverage 
will be available for another illness. See supra, at 432. For 
that reason among others, HHS has noted, the stoppage of 
payment for any given service cannot be thought to affect 
the broader statutory entitlement to Part A benefts. See 
69 Fed. Reg. 49098. That entitlement arises when a person 
meets the basic statutory qualifcations and (unless a disabil-
ity diminishes) never goes away. 
If “entitled to [Part A] benefts” instead bore Empire's 
meaning, Medicare benefciaries would lose important rights 
and protections. Perhaps most signifcantly, a patient could 
lose his ability to enroll in other Medicare programs when-
ever he lacked a right to Part A payments for hospital care. 
As noted earlier, a person's entitlement to Part A benefts is 
usually the predicate for his enrollment in Part B (covering

438 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
outpatient care), Part C (providing coverage through pri-
vately managed plans), or Part D (offering prescription-drug 
benefts). See §§ 1395o(a), 1395w–21(a)(3), 1395w–101(a)(3) 
(A); supra, at 429. So if (as Empire urges) a hospitalized 
patient is not “entitled to [Part A] benefts” on any day he 
cannot get Part A payments, then he could be locked out of 
the benefts of Parts B through D at that time. Consider 
what that might mean in the real world: A Medicare patient 
in the hospital for longer than 90 days—by defnition, a very 
ill person—could not enroll in Part D's prescription-drug 
coverage. Congress could not have wanted—and in fact did 
not provide for—that result. 
Empire's interpretation would also make a hash of provi-
sions designed to inform Medicare benefciaries of their ben-
efts. The statute requires annual notice to individuals 
“entitled to benefts under part A” concerning all available 
program benefts, including any “limitations on payment.” 
§ 1395b–2(a). Under Empire's reading, that notice require-
ment would phase in and out depending on whether Medicare 
Part A was currently paying for the individual's hospital 
treatment. HHS, for example, would have no obligation to 
inform a patient of benefts when a private insurer was pay-
ing for his hospital care, even if that policy would soon run 
out and Medicare would assume the coverage. Once again, 
Congress would not have drafted such an on-again, off-again 
notice requirement. 
So too, Empire's reading of “entitled to [Part A] benefts” 
would subvert a provision to protect benefciaries from mis-
leading marketing materials. Under the statute, an insurer 
offering a Part C (privately managed Medicare) plan may 
not distribute advertising materials to eligible benefciaries 
unless the materials are frst cleared by HHS. See § 1395w– 
21(h)(1). Eligible benefciaries are individuals “entitled to 
benefts under Part A” and enrolled in Part B. § 1395w– 
21(a)(3). If Empire is right about what the “entitled to” 
phrase means, an insurer could send whatever it wanted to 
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Opinion of the Court 
a patient who at that time lacked a right to Part A payments. 
But such a person might well be interested in eventually 
enrolling in a Part C plan—and he is no less vulnerable to 
deceptive marketing than anyone else. 
And the problems with Empire's interpretation do not stop 
there. The Sixth and D. C. Circuits have cataloged several 
other statutory provisions that Empire's reading would ren-
der unworkable or unthinkable or both. See Metropolitan 
Hospital, 712 F. 3d, at 260; Northeast Hospital Corp. v. Sebe-
lius, 657 F. 3d 1, 6–11 (CADC 2011). We could spell out each 
one in painful detail, but we think the above should suffce. 
Applying Empire's reading of “entitled to [Part A] benefts” 
across the Medicare statute would diminish the benefciary 
protections Congress wrote into law. Those safeguards 
would apply or not apply, or fuctuate constantly between the 
two, based on the happenstance of whether Medicare paid 
for hospital care on a given day. Once again, that is not the 
statute Congress wrote. 
2 
Faced with these many provisions, Empire swerves. Em-
pire effectively (if reluctantly) concedes that its reading of 
“entitled to [Part A] benefts”—again, to have an “absolute 
right” to Part A payments—cannot be applied throughout 
the Medicare statute. Brief for Respondent 30; see id., at 
41–42; Tr. of Oral Arg. 37–39. There, over and over—and 
contra the main thrust of Empire's arguments—the concepts 
of entitlement and eligibility are the same. So Empire must 
come up with a way of converting the ordinary meaning of 
“entitled” in the Medicare law to something different in its 
fraction provisions. The lever Empire proposes to use for 
that purpose is the parenthetical phrase “(for such days).” 
See Tr. of Oral Arg. 38–39 (“[T]he key distinction” is “for 
such days,” which is “language that's not found anywhere 
else”). Empire argues that when “entitled” is married to 
“(for such days)”—recall the whole phrase, “patients who (for 
such days) were entitled to [Part A] benefts”—the idea of 
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440 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
entitlement morphs. § 1395ww(d)(5)(F)(vi)(I). Now it does 
not mean meeting Medicare's statutory (age or disability) cri-
teria on the days in question, but instead means actually re-
ceiving Medicare payments. (The dissent makes much the 
same argument.) 
But we cannot understand Congress to have changed the 
statute's consistent meaning of “entitled to benefts” simply 
by adding “(for such days).” That slight phrase is incapable 
of bearing so much interpretive weight. If Congress “does 
not alter the fundamental[s]” of a statutory scheme “in vague 
terms or ancillary provisions,” then it ordinarily does not do 
so in parentheticals either. Whitman v. American Truck-
ing Assns., Inc., 531 U. S. 457, 468 (2001). To the contrary, 
a parenthetical is “typically used to convey an aside or after-
thought.” Boechler v. Commissioner, 596 U. S. 199, 206 
(2022) (internal quotation marks omitted). And nothing 
about the “(for such days)” parenthetical signals anything 
different. Empire asks us to read it as transforming the 
uniform statutory meaning of “entitled to benefts” for the 
fraction provisions alone. But if Congress had wanted to 
accomplish that unexpected object, it would simply have said 
so. Or else, to make only paid-for days count, it would have 
dropped the language of entitlement altogether. What it 
would not have done is upend the settled meaning of that 
language, in this one place, through so subtle, indirect, and 
opaque a mechanism. 
The “(for such days)” phrase instead works as HHS says: 
hand in hand with the ordinary statutory meaning of “enti-
tled to [Part A] benefts.” The parenthetical no doubt tells 
HHS to ask about a patient on a given day. But the query 
the agency must make is not whether that patient on that 
day has received Part A payments; the query is, consistent 
with what “entitled” means all over the statute, whether that 
patient on that day is qualifed to do so. Suppose, for exam-
ple, that a patient turns 65 halfway through a 30-day hospi-
tal stay. HHS will then count only 15 days of his stay 
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Opinion of the Court 
when computing the Medicare fraction. Or suppose, simi-
larly, that midway through his stay, a patient begins to qual-
ify as disabled—because, under the statutory defnition, he 
has reached his 25th month of federal disability benefts. 
Then, too, only the second half of the patient's stay would go 
into the fraction—because only then has he met the criteria 
for benefts. 
Empire complains that the phrase “(for such days),” 
viewed in that way, does too “little work.” Brief for Re-
spondent 38; Tr. of Oral Arg. 40–41. But it does more than 
enough. Some 10,000 people turn 65 in this country every 
day, thus qualifying for Medicare coverage. See American 
Assn. of Retired Persons, The Aging Readiness & Competi-
tiveness Report: United States 2, https://arc.aarpinter 
national.org / File%20Library/ Full%20Reports/ARC -
Report-United-States.pdf. Many other individuals daily at-
tain their 25th month on federal disability benefts. It is 
natural for Congress to have thought of those facts when 
devising the fractions. By the way, said Congress (in what 
truly is an “aside or afterthought”): If someone turns 65 dur-
ing the year the fraction covers, make sure to exclude his 
pre-birthday hospital days. Boechler, 596 U. S., at 206 (in-
ternal quotation marks omitted). Only count the days after 
he qualifes for Medicare Part A—when, under the statute's 
constant meaning, he is “entitled to [Part A] benefts.” 
4 
4 The dissent has another complaint: that from 1986 until 2003 HHS read 
the “for such days” phrase in the Medicare fraction just as Empire does, 
and that the Department changed its view merely to reduce payments to 
hospitals. See post, at 446–447 (opinion of Kavanaugh, J.). But that is 
an incomplete—leading to an inaccurate—picture. From 1986 to 1997, 
HHS read both the Medicare and the Medicaid fractions as counting only 
days actually paid for. The effect on the Medicaid side was to substan-
tially depress payments to hospitals (because many low-income patients 
were excluded from the numerator, while the denominator remained the 
same, see supra, at 431, and n. 1). Hospitals sued, and four Circuit Courts 
found that HHS's understanding of the “for such days” language in the 
Medicaid fraction was wrong. See Brief for United States 12–13 (collect-

442 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
B 
The structure of the relevant statutory provisions rein-
forces our conclusion that “entitled to [Part A] benefts” 
means qualifying for those benefts, and nothing more. As 
earlier explained, the statute is designed to recompense hos-
pitals for serving low-income patients, who are compar-
atively more expensive to treat. See supra , at 429. The 
statute determines the appropriate payment (if any) by 
measuring, through two separate fractions, two separate 
populations: the low-income Medicare population and the low-
income non-Medicare population. See supra, at 429–430.
5 
(Because the vast majority of Medicare patients are over 65, 
that roughly translates into the low-income senior population 
and the low-income non-senior population.) Those popula-
tions, taken together, account for all the low-income patients a 
hospital treats. 
HHS's reading of “entitled” comports with the statute's 
two-population structure. A low-income Medicare patient 
always counts in the Medicare fraction. That is so regard-
less of whether the Medicare program is actually paying for 
a day of his care—because that fact has no relationship to 
his fnancial status. The Medicare fraction, as calculated by 
HHS, thus captures the entire low-income Medicare (i. e., se-
nior) population. And correlatively, the Medicaid fraction 
captures the entire low-income non-Medicare (i. e., non-
senior) population. The binary dividing line HHS uses—do 
ing citations). In response, HHS immediately corrected its approach to 
the Medicaid fraction—which signifcantly raised payments to hospitals. 
Some fve years later, HHS issued a rule to bring its reading of the same 
language in the Medicare fraction into line. The history shows, then, that 
HHS “changed course” not “to save money” but to comply with the law. 
Post, at 446. 
5 As noted earlier, see supra, at 431, n. 1, the two populations (because 
of their fractions' different denominators) are differently weighted in cal-
culating DSH payments. All else equal, a hospital receives greater com-
pensation for low-income individuals in the Medicare population than for 
low-income individuals in the non-Medicare population. 
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Opinion of the Court 
you qualify for Medicare?—mirrors the statute's binary, 
population-focused framework. All low-income people ft 
naturally into one or the other box, with the sum of the two 
leaving no one out. 
By contrast, Empire's view fts poorly with the bifurcated, 
population-based statutory structure. Again, its who-paid-
for-a-day-of-care test has no relationship to a patient's fnan-
cial status. So on Empire's view, a patient could phase in 
and out of the Medicare fraction even though his income re-
mains the same. Empire responds by asserting that any 
low-income person excluded from the Medicare fraction (say, 
because of exhaustion of benefts) would get counted instead 
in the Medicaid fraction. See Brief for Respondent 15–16, 
50–51. But even if that is true—we express our doubts 
below—Empire's scheme would result in patients ping-
ponging back and forth between the two fractions based on 
the happenstance of actual Medicare payments, sometimes 
during a single hospital stay. That scheme is of course 
harder to administer than HHS's. And still more, it does 
not refect the statute's dichotomy between two discrete low-
income populations, each of which counts (but counts differ-
ently) toward setting a hospital's DSH rate. See supra, at 
431, n. 1, 442, n. 5. 
In any event, Empire is too quick to claim that those who 
(on its view) are tossed from the Medicare fraction for non-
income-based reasons would still wind up in the Medicaid 
fraction. Recall here the role Empire says the phrase “(for 
such days)” plays. See supra, at 439–441. According to 
Empire's ultimate argument, that phrase is what converts 
the ordinary statutory meaning of “entitled to benefts” (i. e., 
qualifying for Medicare) to a special meaning (i. e., actually 
receiving payments). So where the phrase “(for such days)” 
does not appear, the usual meaning of “entitled” should gov-
ern. Now look again at the description of the Medicaid frac-
tion. It counts “patients [i] who (for such days) were eligi-
ble for [Medicaid], but [ii] who were not entitled to benefts 
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444 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Opinion of the Court 
under part A [of Medicare].” § 1395ww(d)(5)(F)(vi)(II). In 
that description, “for such days” does not modify clause [ii]. 
So the “not entitled” phrase in that clause should mean (con-
sistent with the rest of the statute) not qualifying for Medi-
care. But those whom Empire's view would oust from the 
Medicare fraction—say, because of exhaustion—do qualify 
for Medicare. They thus fall outside clause [ii]—and outside 
the Medicaid fraction. The upshot is that, under Empire's 
reading, a low-income patient who, say, has exhausted his 
coverage will not get counted at all. But that person re-
mains just as low income as he ever was, imposing just as 
high costs on the hospital treating him. His exclusion dem-
onstrates, if anything more needs to, the error of Empire's 
reading. 
Empire's only response is to insist that its interpretation 
has to be right because it usually (though not always) leads 
to higher DSH payments for hospitals. See Brief for Re-
spondent 33–35; supra, at 432–433. But the point of the DSH 
provisions is not to pay hospitals the most money possible; 
it is instead to compensate hospitals for serving a dispropor-
tionate share of low-income patients. And Empire's reading 
excels only by the former measure, not by the latter one. 
As just shown, Empire's actual-payment test counts fewer, 
not more, of the low-income patients the DSH provisions 
care about. The reason that approach still benefts many 
hospitals is that it defates the denominator of the Medicare 
fraction. Consider a wealthy 70-year-old patient who has 
exhausted Medicare benefts—or, as is often true, has a pri-
vate insurance policy. HHS's view would exclude him from 
the Medicare fraction's numerator (because he is wealthy) 
but keep him in the denominator (because he is over 65). 
By contrast, Empire's view would exclude him from both the 
numerator and the denominator—the latter because he is not 
actually receiving Medicare payments. That move in-
creases payments to hospitals—but only because it fails to 
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Kavanaugh, J., dissenting 
capture high-income Medicare patients, not because it better 
captures low-income ones. Or said otherwise, it increases 
payments because it distorts what the Medicare fraction is 
designed to measure—the share of low-income Medicare pa-
tients relative to the total. 
III 
Text, context, and structure all support calculating the 
Medicare fraction HHS's way. In that fraction, individuals 
“entitled to [Medicare Part A] benefts” are all those qualify-
ing for the program, regardless of whether they are receiv-
ing Medicare payments for part or all of a hospital stay. 
That reading gives the “entitled” phrase the same meaning 
it has throughout the Medicare statute. And it best imple-
ments the statute's bifurcated framework by capturing low-
income individuals in each of two distinct populations a 
hospital serves. 
For those reasons, we reverse the judgment of the Court 
of Appeals and remand the case for further proceedings con-
sistent with this opinion. 
It is so ordered. 
Justice Kavanaugh, with whom The Chief Justice, 
Justice Alito, and Justice Gorsuch join, dissenting. 
Under the Medicare statute, HHS pays higher reimburse-
ments to hospitals that serve a signifcant number of low-
income patients. The statutory formula for determining 
exactly how much HHS will pay to those hospitals is mind-
numbingly complex. But embedded within the complicated 
overall formula are various subsidiary calculations, some of 
which are relatively straightforward. 
This case concerns one of those straightforward subsidiary 
calculations. Consistent with traditional insurance and 
coordination-of-benefts principles, Medicare by statute can-
not pay for a patient's hospital care if, for example, the pa-
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446 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Kavanaugh, J., dissenting 
tient is covered by private insurance, the patient has ex-
hausted her Medicare benefts, or a third-party tortfeasor is 
liable for the patient's care. The retrospective reimburse-
ment question raised by the statutory provision in this case 
is this: Was a patient “entitled to” have payment made by 
Medicare for a particular day in the hospital if the patient 
by statute could not (and did not) have payment made by 
Medicare for that day? In my view, the answer to that nar-
row question is straightforward and commonsensical: No. 
Importantly, from the time the statute was enacted in 1986 
until 2003, HHS interpreted this statutory provision in 
the exact same way that I do. See 51 Fed. Reg. 31460− 
31461 (1986); Brief for Petitioner 32−33. Then in 2004, 
HHS abruptly changed course. Why? Presumably to save 
money. HHS was trying hard to fnd ways to contain Medi-
care costs in light of increasing Medicare expenditures and 
the country's fscal situation. To that end, HHS's new 2004 
interpretation of this statutory provision had the down-
stream effect of signifcantly reducing HHS's reimburse-
ments to hospitals that serve low-income patients. 
Whatever HHS's precise motivations for the 2004 change, 
we now must focus on the statutory text and HHS's current 
interpretation of it. To begin, both parties offer a dog's 
breakfast of arguments about broad statutory purposes, real-
world effects, surplusage, structure, consistent usage, incon-
sistent usage, agency deference, and the like. But this case 
is resolved by the most fundamental principle of statutory 
interpretation: Read the statute. 
The relevant text of this reimbursement provision refers 
to “the number of . . . patient days . . . which were made up 
of patients who (for such days) were entitled to benefts 
under part A.” 42 U. S. C. § 1395ww(d)(5)(F)(vi)(I). Impor-
tantly, the statute elsewhere says that “[t]he benefts pro-
vided” under Medicare Part A consist of a patient's “entitle-
ment to have payment made on his behalf . . . (subject to the 
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Cite as: 597 U. S. 424 (2022) 447 
Kavanaugh, J., dissenting 
provisions of this part).” § 1395d(a) (emphasis added); see 
also § 426(c) (“entitlement” means “entitlement to have pay-
ment made under, and subject to the limitations in, part A” 
(emphasis added)). 
Zero in on the phrases “entitlement to have payment 
made” and “for such days.” In my view (and in HHS's view 
from 1986 to 2003), a patient was entitled to have payment 
made by Medicare for particular days in the hospital if Medi-
care was obligated to pay for the patient's care for those 
days. Stated the other way, a patient was not entitled to 
have payment made by Medicare for particular days in the 
hospital if the patient by statute could not (and did not) have 
payment made by Medicare for those days—for example, be-
cause the patient had other insurance, the patient had ex-
hausted his Medicare benefts, or a third-party tortfeasor 
was paying. Simple enough. 
To be sure, patients who satisfy certain criteria (for exam-
ple, those who are age 65 or older) are generally “entitled” 
to Medicare hospitalization benefts. No one disputes that 
point. But this reimbursement provision looks to whether 
the patient was entitled to have payment made by Medicare 
for a particular day in the hospital. And the answer to that 
question is no if Medicare by statute could not (and did not) 
pay for that day in the hospital. 
Suppose that a college says that your academic record enti-
tles you to a scholarship for next year if your family's income 
is under $60,000, unless you have received another scholar-
ship. And suppose that your family's income is under 
$60,000, but you have received another scholarship. Are 
you still entitled to the frst scholarship? Of course not. So 
too here. 
The Court concludes otherwise, mainly by (i) saying that 
“entitled to benefts” is a term of art in the Medicare statute, 
(ii) diminishing the value of the statutory phrase “(for such 
days),” in part because the phrase appears in a parenthetical, 
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448 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR 
V ALLEY HOSPITAL MEDICAL CENTER 
Kavanaugh, J., dissenting 
and (iii) invoking a parade of horribles about what could hap-
pen to other provisions of the Medicare statute if the Court 
were to read this provision as I would. 
With respect, none of that adds up. First, although the 
Medicare statute generally uses “entitled” to refer to those 
who meet the basic statutory criteria for Medicare benefts, 
the retrospective reimbursement provision at issue here fo-
cuses laser-like on whether the patient was actually entitled 
to have payment made by Medicare for particular days in 
the hospital. A patient cannot be simultaneously entitled 
and disentitled to have payment made by Medicare for a par-
ticular day in the hospital. 
Second, contrary to the Court's suggestion, we cannot 
brush aside the statutory phrase “(for such days)” simply 
because that phrase appears in a parenthetical. See Dun-
can v. Walker, 533 U. S. 167, 174 (2001). Parentheticals can 
be important, as the Constitution itself makes clear. See, 
e. g., Art. I, § 7 (counting days for bill to become law with 
“(Sundays excepted)”); Art. IV , § 4 (affording federal protec-
tion to States on application by the Executive but only 
“(when the Legislature cannot be convened)”). 
Third, properly interpreting this specifc reimbursement 
provision will not “make a hash” of other provisions or ren-
der the Medicare statute “unworkable.” Ante, at 438−439. 
We need not speculate about that point: For nearly two dec-
ades from the time that the statute was enacted in 1986 
through 2003, HHS interpreted this reimbursement provi-
sion in the same way that I do. And HHS did so without 
any noted problems for other provisions in the Medicare 
statute. 
To sum up: A patient was not entitled to have payment 
made by Medicare “for such days” in the hospital if the pa-
tient by statute could not (and thus did not) have payment 
made by Medicare for those days—for example, because pri-
vate insurance was already covering the patient's care, or 
the patient had exhausted his Medicare benefts. Both stat-
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Kavanaugh, J., dissenting 
utory text and common sense point to that conclusion. 
HHS's contrary interpretation boils down to the proposition 
that a patient can be simultaneously entitled and disentitled 
to have payment made by Medicare for a particular day in 
the hospital. That interpretation does not work. And 
HHS's misreading of the statute has signifcant real-world 
effects: It fnancially harms hospitals that serve low-income 
patients, thereby hamstringing those hospitals' ability to 
provide needed care to low-income communities. 
In my view, HHS's 2004 interpretation is not the best 
reading of this statutory reimbursement provision. I re-
spectfully dissent. 
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Reporter’s Note 
The attached opinion has been revised to refect the usual publication 
and citation style of the United States Reports. The revised pagination 
makes available the offcial United States Reports citation in advance of 
publication. The syllabus has been prepared by the Reporter of Decisions 
for the convenience of the reader and constitutes no part of the opinion of 
the Court. A list of counsel who argued or fled briefs in this case, and 
who were members of the bar of this Court at the time this case was 
argued, has been inserted following the syllabus. Other revisions may 
include adjustments to formatting, captions, citation form, and any errant 
punctuation. The following additional edits were made: 
None

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• #1

  PRELIMINARY PRINT Volume 597 U. S. Part 1 Pages 424–449 OFFICIAL REPORTS OF THE SUPREME COURT June 24, 2022 REBECCA A. WOMELDORF reporter of decisions Page Proof Pending Publication NOTICE: This preliminary print is subject to formal revision before the bound volume is published. Users are requested to noti…

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  pay for on a given day are patients “who (for such days) were entitled to [Medicare Part A] benefts” for purposes of computing a hospital's disproportionate-patient percentage. § 1395ww(d)(5)(F)(vi)(I). A 2004 HHS regulation says yes: If the patient meets the basic statu- tory criteria for Medicare (i. e., is over…

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  disabled. And in the end, Empire basically concedes that point. It must devise a way to give “entitled to benefts” a different meaning in the fraction descriptions than everywhere else in the Medicare statute. So Empire shifts gears, relying now on the parenthetical phrase “(for such days)” to transform the usual …

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  constantly, based on the happenstance of whether Medicare paid for hos- pital care on a given day. Pp. 435–439. (2) Empire concedes that its interpretation cannot be applied throughout the Medicare statute. To get around this, Empire claims that the parenthetical in “patients who (for such days) were entitled to …

• #5

  patient who has exhausted his coverage would not get counted at all, in either fraction, but he would remain just as low-income and impose just as high costs on the hospital treating him. Empire's only response is to insist that its interpretation must be right because it usually (though not always) leads to highe…

• #6

  ment of Health and Human Services (HHS), a person is “enti- tled to [Part A] benefts” under the statute if he qualifes for the Medicare program—essentially, if he is over 65 or dis- abled. That remains so even when Medicare is not paying for part or all of his hospital stay—for example, because a private insurer …

• #7

  income patients” enhanced Medicare payments. Sebelius v. Auburn Regional Medical Center , 568 U. S. 145, 150 (2013). The mark-up refects that low-income individuals are often more expensive to treat than higher income ones, even for the same medical conditions. In compensating for that dis- parity, the DSH adjust…

• #8

  worse). So again, in general terms: The numerator is the number of patient days attributable to Medicare patients who are poor. The denominator is the number of patient days attributable to all Medicare patients. Divide the for- mer by the latter to get the fraction “expressed as a percent- age.” Ibid. Page Proo…

• #9

  cuses on a hospital's Medicaid population. See 42 U. S. C. § 1396r–4. But that statutory provision is not at issue here.) Page Proof Pending Publication Page Proof Pending Publication 432 BECERRA v. EMPIRE HEALTH FOUNDATION, FOR V ALLEY HOSPITAL MEDICAL CENTER Opinion of the Court care fraction is 10% and its M…

• #10

  those “not entitled to [Medicare Part A] benefts”). See ibid. As HHS explained in 2004, the effect of the regulation varies depending on the makeup of a hospital's patient popu- lation. See ibid. But for most hospitals, the regulation has worked to decrease DSH payments, because as benefciaries are added to the M…

• #11

  guage at issue. The ordinary meaning of the fraction de- scriptions, as is obvious to any ordinary reader, does not exactly leap off the page. See Catholic Health Initiatives, 718 F. 3d, at 916 (The “language is downright byzantine”). The provisions are technical: They call to mind Justice Frankfurter's injunctio…

• #12

  phrase has everywhere else in the Medicare law. See Tr. of Oral Arg. 37–41. So Empire shifts gears, relying now on the parenthetical phrase “(for such days)” to do its work—to transform the usual statutory meaning of “entitled to bene- fts” to something different and novel. See ibid.; § 1395ww (d)(5)(F)(vi)(I) (“…

• #13

  ment made under, and subject to the limitations in, part A.” § 426(c)(1); see § 1395d(a) (similarly stating that the entitle- ment to benefts entails the receipt of “payment[s] . . . subject to the provisions of this part”). Those limits on payment include, as described earlier, the 90-day hospital-stay cap. See …

• #14

  tient coverage may still be entitled to other Part A benefts.” 69 Fed. Reg. 49098. Medicare Part A also covers, “for ex- ample, certain physician services and skilled nursing serv- ices” outside the hospital setting. See CMS–1498–R, at 10. And even as to hospital care, another 90 days of coverage will be availabl…

• #15

  inform a patient of benefts when a private insurer was pay- ing for his hospital care, even if that policy would soon run out and Medicare would assume the coverage. Once again, Congress would not have drafted such an on-again, off-again notice requirement. So too, Empire's reading of “entitled to [Part A] beneft…

• #16

  come up with a way of converting the ordinary meaning of “entitled” in the Medicare law to something different in its fraction provisions. The lever Empire proposes to use for that purpose is the parenthetical phrase “(for such days).” See Tr. of Oral Arg. 38–39 (“[T]he key distinction” is “for such days,” which …

• #17

  day has received Part A payments; the query is, consistent with what “entitled” means all over the statute, whether that patient on that day is qualifed to do so. Suppose, for exam- ple, that a patient turns 65 halfway through a 30-day hospi- tal stay. HHS will then count only 15 days of his stay Page Proof Pendi…

• #18

  were excluded from the numerator, while the denominator remained the same, see supra, at 431, and n. 1). Hospitals sued, and four Circuit Courts found that HHS's understanding of the “for such days” language in the Medicaid fraction was wrong. See Brief for United States 12–13 (collect- 442 BECERRA v. EMPIRE HEALT…

• #19

  pensation for low-income individuals in the Medicare population than for low-income individuals in the non-Medicare population. Page Proof Pending Publication Cite as: 597 U. S. 424 (2022) 443 Opinion of the Court you qualify for Medicare?—mirrors the statute's binary, population-focused framework. All low-incom…

• #20

  that description, “for such days” does not modify clause [ii]. So the “not entitled” phrase in that clause should mean (con- sistent with the rest of the statute) not qualifying for Medi- care. But those whom Empire's view would oust from the Medicare fraction—say, because of exhaustion—do qualify for Medicare. T…

• #21

  “entitled to [Medicare Part A] benefts” are all those qualify- ing for the program, regardless of whether they are receiv- ing Medicare payments for part or all of a hospital stay. That reading gives the “entitled” phrase the same meaning it has throughout the Medicare statute. And it best imple- ments the statut…

• #22

  interpretation of this statutory provision had the down- stream effect of signifcantly reducing HHS's reimburse- ments to hospitals that serve low-income patients. Whatever HHS's precise motivations for the 2004 change, we now must focus on the statutory text and HHS's current interpretation of it. To begin, both…

• #23

  Suppose that a college says that your academic record enti- tles you to a scholarship for next year if your family's income is under $60,000, unless you have received another scholar- ship. And suppose that your family's income is under $60,000, but you have received another scholarship. Are you still entitled to…

• #24

  made by Medicare “for such days” in the hospital if the pa- tient by statute could not (and thus did not) have payment made by Medicare for those days—for example, because pri- vate insurance was already covering the patient's care, or the patient had exhausted his Medicare benefts. Both stat- Page Proof Pending …