PARTS 400-404 [RESERVED]

405.105 Hospital insurance entitlement based on entitlement to disability insurance benefits.

405.106 Premium hospital insurance. 405.110 Inpatient hospital services; scope of benefits.

405.111 Inpatient hospital services; benefit limitation during first spell of illnessinpatient of participating tuberculosis or psychiatric hospital.

405.112 Inpatient hospital services; services considered for purposes of benefit limitations.

405.113 Inpatient hospital services; deductible.

405.114 Inpatient hospital services; whole blood cost deductible.

405.115 Inpatient hospital services; coinsurance amount.

405.116 Inpatient hospital services; defined.

405.117 Inpatient hospital services; kidney donors.

405.118 Election not to use lifetime reserve days.

405.119 Revocation of election.

405.120 Posthospital extended care services; scope of benefits.

405.122 Posthospital extended care services; services considered for purposes of limitation on days of coverage.

405.123 Posthospital extended care services; whole blood cost deductible.

Sec.

405.124 Posthospital extended care services; coinsurance amount.

405.125

Extended care services; defined. 405.126 Posthospital extended care; level of care requirements.

405.127 Posthospital extended care; skilled nursing and rehabilitation services. 405.128 Posthospital extended care; frequency of services; "daily basis." 405.128a Posthospital extended care; need for institutionalization; "practical matter."

405.130 Posthospital home health services; general.

405.131 Posthospital home health services; benefits provided.

405.133 Post-hospital extended care and post-hospital home health services; presumed coverage procedure.

405.150 Payment for services furnished; general.

405.151 Payment for services furnished; determination of amount payable based on reasonable cost.

405.152 Payment for services furnished; nonparticipating hospital furnishing emergency services.

405.153 Payment for services; hospital outside the United States.

405.157 Payment to entitled individual for

emergency services furnished after 1967. 405.158 Payment to entitled individual; determination of amount payable for services furnished by a nonparticipating hospital.

405.160 Payment to participating hospital for inpatient hospital services; conditions for payment.

405.161 Payment for inpatient hospital services; furnished after 90- or 150-day limit or after 190-day limit.

405.162 Prohibition against payment for inpatient hospital services furnished after utilization review finding that further services are not medically neces

sary. 405.163 Prohibition against payment for inpatient hospital services furnished after 20th consecutive day by a hospital which has failed to make timely utilization review.

tended care services; conditions. 405.166 Prohibition against payment for post-hospital extended care services furnished after a utilization review finding that services are not medically necessary. 405.167 Prohibition against payment for services furnished by a facility which fails to make timely utilization review. 405.170 Payment for posthospital home health services; conditions.

405.180 No payment for services furnished to an alien before the first full calendar month in the United States. 405.181 Individual convicted of subversive activities; effect on entitlement. 405.191 Emergency services; finding that an emergency existed and/or has ceased. 405.192 Emergency services; finding of ac

Sec.

405.231 Medical and other health services; included items and services.

405.232 Medical and other health services; conditions, limitations, and exclusions. 405.232a Physician defined. 405.232b Chiropractors.

405.232c Optometrists.

405.233 Home health services; general. 405.234 Home health services; conditions. 405.235 Home health services; place where items and services must be furnished. 405.236 Home health services; items and services included.

405.237 Home health services; items and services not included.

405.238 Home health services; "visits" defined.

405.239 Option available to patients under a home health plan who require physical therapy or speech therapy services. 405.240 Payment of supplementary medical insurance benefits; amounts payable. 405.241 Payment of supplementary medical insurance benefits; election by group-practice prepayment plan as to method of determining amount of payment.

405.243 Psychiatric services limitation; expenses incurred for physician services. 405.244 Incurred expenses; expenses excluded from total expenses or not considered for purposes of the deductibles. 405.244-1 Payment of supplementary medical insurance benefits; kidney donor services.

405.245 The supplementary medical insurance benefits deductible.

405.246 Supplementary medical insurance blood deductible.

405.249 Payment to a nonparticipating hospital furnishing emergency outpatient services.

405.250 Procedures for payment; medical and other health services furnished by participating provider or ESRD facility; home health services. 405.250-1 Outpatient physical therapy and speech pathology services furnished by participating provider; plan of treatment requirements.

405.250-2 Procedures for payment; rural health clinic services furnished by a rural health clinic.

405.251 Procedures for payment; medical and other health services furnished by other than a participating provider or ESRD facility.

405.252 Conditions prohibiting payment of

benefits.

Subpart C-Exclusions, Recovery of Overpayment, Liability of a Certifying Officer and Suspension of Payment

405.301 Scope of subpart.

Sec.

405.310 Types of expenses not covered. 405.310-1 Nonreimbursable expenses; conclusive effect of PSRO determinations on claims payment.

405.311 Nonreimbursable expenses; individual has no legal obligation to pay for items or services.

405.311a Nonreimbursable expenses; items or services furnished by a Federal provider of services or other Federal agency.

405.311b Nonreimbursable expenses; items or services which a provider or other person is obligated to furnish at public expense under a law of, or contract with, the United States.

405.312 Nonreimbursable expenses; items or services paid for by governmental entity.

435.313 Nonreimbursable expenses; items or services not provided in the United States.

405.314 Nonreimbursable expenses; items or services required as a result of war. 405.315 Nonreimbursable expenses; charges imposed by immediate relatives or members of beneficaries' household. 405.316 Nonreimbursable expenses;

pay

405.332 Criteria for determining that there was knowledge that certain services were nonreimbursable.

405.350 Individual's liability for payments

made to providers and other persons for items and services furnished the individual.

405.351 Incorrect payments for which the individual is not liable.

405.352 Adjustment of title XVIII incorrect payments.

405.353 Certification of amount that will

be adjusted against individual title II or railroad retirement benefits. 405.354 Procedures for adjustment or recovery-title II beneficiary. 405.355 Waiver of adjustment or recovery. 405.356 Principles applied in waiver of adjustment or recovery.

405.402 Cost reimbursement; general. 405.403 Apportionment of allowable costs. 405.404 Methods of apportionment under title XVIII.

405.405 Payments to providers; general. 405.406 Financial data and reports. 405.415 Depreciation: Allowance for depreciation based on asset costs. 405.416 Depreciation: optional allowance for depreciation based on a percentage of operating costs.

405.417 Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.

405.418 Depreciation: Allowance for depreciation on assets financed with Federal or public funds.

405.419 Interest expense.

405.420 Bad debts, charity, and courtesy allowances.

405.421 Cost of educational activities. 405.422

Research costs.

405.423 Grants, gifts, and income from endowments.

405.424 Value of services of nonpaid work

ers.

405.425 Purchase discounts and allowances, and refunds of expenses.

405.426 Compensation of owners. 405.427 Cost to related organizations. 405.428 Allowance in lieu of specific recognition of other costs.

405.429 Return on equity capital of proprietary providers.

405.430 Inpatient routine nursing salary cost differential.

405.432 Reasonable cost of physical and other therapy services furnished under arrangements.

405.433 Determining allowable cost for drugs.

405.435 Nonallowable costs related to certain capital expenditures. 405.436 Reimbursement of independent organ procurement agencies and histocompatibility laboratories.

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