one-year period for his Part A visits is established dating from his latest discharge. The one-year period during which an individual may have up to 100 home health visits may thus in fact exceed a year overall. (See Example 2 below). The total number of visits available before the next benefit period begins remains unchanged.

The end of the year for hospital insurance purposes is determined as follows:

Count 365 days (366 when February 29 is included) beginning with the latter of the following:

(a) The date of discharge from a 3-day stay in any hospital, or

(b) The date of discharge from an SNF stay for which posthospital extended care benefits were payable on the patient's behalf.

EXAMPLE 1: Mr. Sam Jones is hospitalized on February 10 and discharged on March 5, 1970; he had no other hospital or SNF stay in 1970, or 1971. He has 100 home health visits beginning the latter part of March and ending on February 20, 1971. All 100 visits are paid for under hospital insurance since the one-year period runs from March 15, 1970 (the date of the hospital discharge), to March 14, 1971. Although Mr. Jones' benefit period ended on May 13, 1970, 60 days after the hospital discharge, home health eligibility was unaffected since a new benefit period did not begin subsequently.

EXAMPLE 2: Mrs. A. Henderson was an inpatient in a hospital four times during the same benefit period, i.e., there was no period of 60 consecutive days during which she was not hospitalized. She was discharged from the hospital, which meets the requirements to qualify for subsequent home health services for payment under hospital insurance, on March 15, 1970, May 13, 1970, July 12, 1970 and September 9, 1970. Each hospital stay was for at least three consecutive days except the last one. She had home health visits beginning with May 23, 1970, based on a plan established after her hospital discharge of May 13. The one-year period for home health services under hospital insurance began May 13, 1970, the date of her most recent discharge (in relation to the first home health visit in the benefit period) from a hospital after a stay of three days; it can end no later than July 12, 1971, 1 year after the latest discharge from a hospital stay of at least three consecutive days.

EXAMPLE 3: Mr. Henry Smith is hospitalized on February 10, and discharged on March 15. He reenters the hospital on July 4. He had 30 home health visits between March 15 and July 4. Since

he had been out of the hospital for more than 60 days after his discharge on March 15, a new benefit period began on July 4, when he reentered the hospital. Therefore, he is not entitled to any additional home health visits under hospital insurance based on his February-March hospital stay. However, an additional 100 home health visits under hospital insurance may begin based on his hospitalization beginning July 4, if he is confined for at least three days. If he is not confined for at least three days, he will not qualify for home health visits under hospital insurance in the new benefit period.

See $11358 for additional examples and duration of coverage under Part B.

Presumed Coverage of Part A Home Health Services

11186. Presumption of Coverage

Under the 1972 amendments, the Secretary is authorized to guarantee payment for Part A posthospital home health visits made to furnish intermittent skilled nursing care, physical therapy, or speech therapy services (home health services received under the Part B benefit are excluded from presumed coverage) provided that the individual has one or more of a number of medical conditions specified by the Secretary in regulations and provided the beneficiary otherwise qualifies for home health benefits (see §§ 11180 ff.). Payment is guaranteed only where the following conditions are met:

(a) A physician submits to the provider in a timely fashion, prior to the first chargeable posthospital visit made by the HHA, a written certification that the patient is in need of covered care (see $11187);

(b) The certification indicates that the individual's medical condition is one that is set forth in regulations (see §11189);

(c) The certification is accompanied by a written plan of treatment for providing the required posthospital home health services (see §11187); and

(d) The Secretary has not determined that the physician is submitting, with some frequency, erroneous presumed coverage certifications or inappropriate plans of treatment (see §11188).

The provider and intermediary review each presumed coverage claim to ensure that the above requirements are met. If not met, the presumed coverage provision does not apply and the case is processed as a regular home health claim. The use of the presumed coverage provision is optional, to

be initiated solely at the discretion of the physician. Therefore, intermediaries and providers do not attempt to establish rules or guidelines making the use of presumed coverage mandatory in cases in which the requirements for such coverage would otherwise be met. A period of presumed coverage can only be established for services furnished on or after June 24, 1976, the effective date established by regulations.

11187. Physician's Plan of Treatment, Certification and Recertification

The physician's certification and plan of treatment must be submitted in writing to the provider in a timely fashion, prior to the first chargeable posthospital home health visit made to the patient. The requirement in § 11181 that the posthospital home health plan of treatment must be established within 14 days of the patients discharge from a qualifying inpatient stay must also be met.) The first chargeable visit does not include the initial evaluation visit made to the home to determine whether needed care can be provided in the home setting. Providers forward the physician's certification and plan of treatment to the intermediary before the end of the second day following the day the first chargeable posthospital home health visit is made.

There is no special certification or plan of treatment form for use in presumed coverage cases. Therefore, any format which is agreed upon by both the intermediary and provider may be used. However, home health certifications and plans of treatment should contain all required information, and the certification should state that the patient's condition is one that is listed in the regulations. In addition, all documents, e.g., certification, plan of treatment, etc., and the bill should have the words "Presumed Coverage Case" typed at the top. If desired, both the physician's certification and plan of treatment may be included in the same form.

(a) Treatment Plan

A plan of care that meets the requirements of § 11165(b)(2) also meets the plan of treatment requirements for purposes of the presumed coverage provision. The plan should show not only the home health services to be furnished which are covered under the presumed coverage provision, but all other covered home health services required as well. The plan of treatment must be established by the same physician who signs the certification. (b) Physician's Recertification

The regular requirements for recertification for home health benefits apply in connection with

presumed coverage cases, i.e.. the first recertification should be made no later than 2 months after the beginning of the presumed coverage period. It is not necessary for a physician to recertify the patient's need for continuing care (or establish a new plan of treatment) at the end of the presumed coverage period.

11188. Revocation of Presumption for Certain Physicians

Where the Secretary determines that a physician is submitting with some frequency erroneous presumed coverage certifications and/or inappropriate plans of treatment, the physician's certifications and plans will not be acceptable for purposes of the presumed coverage provision, starting with the effective date of such determination. Intermediaries maintain review procedures capable of identifying indications of possible erroneous certifications and also for investigating whether there is evidence to support such a determination by the Secretary. Intermediaries establish a mechanism for developing a profile for each physician in their service areas who submits certifications and plans under the presumed coverage provision from which it will be possible to determine the number of presumed coverage certifications and plans of treatment the physician has submitted in any given period of time and how many during such period appear to be questionable in regard to the accuracy of the certification or appropriateness of the plan of treatment. The profile includes the claims material on which the profile is based or incorporates a procedure that permits the intermediary to identify and retrieve the material if necessary.

11189. Medical Conditions and Periods Covered Under the Presumption

(a) Medical Conditions Covered Under the Presumption

The medical conditions and the number of home health visits guaranteed under the presumed coverage provision are designated in the regulations and in (c) below. The medical conditions listed represent those conditions which generally require a covered level of home health services following hospitalization, considering such factors as the medical severity of such conditions, the degree of incapacity, the type of services required, and the minimum period of home confinement generally needed for such conditions. An individual who needs one of the skilled services described in (c) below is presumed to require skilled nursing care on an intermittent basis or

physical therapy or speech pathology services for the number of home health visits designated. The regulations will be revised periodically to include additional medical conditions which subsequent program experience indicates required covered care.

(b) Periods of Coverage Under the Presumption

The number of home health visits guaranteed under the presumed coverage provision are designated in the regulations and in (c) below. The number of home health visits designated is predicated on the assumption that the length of such visits will be the usual and customary time for such visits. Also, a time frame during which the home health visits are to be made is designated for each medical condition. However, such a designation does not mean that the visit must be allocated in any particular manner during that period of time. The number of visits designated may be allocated in any combination so long as the visits do not exceed the total number of visits shown or the total time frame specified. Where an individual's medical condition necessitates more than one of the types of skilled services specified in (c) below, and each type requires the same kind of visit, e.g., both require skilled nursing visits, the individual is eligible for the presumed number of visits for the skilled service which presumes the larger number of home health visits. However, where each type of skilled service needed requires different kind of visits, e.g., skilled nursing and speech therapy (speech

pathology) visits, the individual is eligible for the presumed number of visits for each type of skilled service.

These presumed periods of coverage are not intended to encompass the entire period of care an individual may require. An indiviiual is eligible to have payment made for additional care beyond the presumed coverage period where he still requires covered care. However, the law permits only one period of presumed coverage for each admission to care by an HHA following a qualifying inpatient stay. If care is required beyond the presumed period (or within the presumed coverage period, in the case of individuals who require additional or other home health services besides those included in the visits specified in the regulations for their medical conditions), a request may be made to the intermediary for additional coverage prior to the end of the presumed coverage period. In making such a request, the provider follows its usual procedure in requesting payment of a claim, but clearly indicates on the form submitted that this is a request for additional coverage in a presumed coverage case. When the intermediary receives the request it makes a determination as to whether further payment is warranted. If it is determined that further care is not warranted, coverage terminates at the end of the presumed coverage period.

(c) Listing of Conditions and Periods Covered Under the Presumption

Skilled Services

care.

Presumed Number of Covered
Home Health Visits

Nine skilled nursing visits in a 3-week period.

Ten skilled nursing visits in a 2-week period.

Five skilled nursing visits in a 2-week period.

Three skilled nursing visits in a 2-week period.

Six skilled nursing visits in a 1-week period.

Eight skilled nursing visits in a 3-week period.

Four skilled nursing or four physical therapy visits in a 2-week period.

Four skilled nursing or four physical therapy visits in a 2-week period.

Three skilled nursing visits in a 2-week period.

Three skilled nursing or four physical therapy visits in a 2-week period.

Skilled Services

11190. Coverage of Home Health

Services in Addition to Those
Covered by the Presumption

Under presumed coverage, home health benefits are guaranteed only for intermittent skilled nursing care, physical therapy, and speech therapy (pathology) services. However, other services such as home health aide services, occupational therapy, medical social services, etc., as well as additional skilled nursing and therapy visits beyond what is allowed during the presumed coverage period, may also be covered. While such services can be paid for during the presumed coverage period, such services are not included under the presumed coverage period. Rather, payment must be made on the basis of an evaluation of the appropriateness of such services in each case. PART IV-DEDUCTIBLES AND COINSURANCE

Act-Sec. 1813

Reg. No. 5 Secs. 405.113-405.115, 405.124

11192. Inpatient Hospital Deductible

The beneficiary is responsible for a deductible amount before the program begins paying for inpatient hospital services in each benefit period. The Secretary determines the amount of the deductible applicable for each year by the relationship between the average amount paid per day for inpatient hospital services during the preceding year and the rate for 1966. The figure thus derived is rounded to the nearest multiple of $4 (or if it's midway between two multiples of $4, to the next higher multiple of $4).

The year in which the patient's benefit period begins determines the deductible amount and related coinsurance amounts applicable in this case.

The following chart shows the applicable deductible amounts for benefit periods beginning in each year since 1974:

Presumed Number of Covered
Home Health Visits

Four skilled nursing visits in a 2-week
period.

Five physical therapy and/or five speech therapy (speech pathology) visits in a 2-week period.

The beneficiary is responsible for a daily coinsurance amount of one-fourth of the inpatient hospital deductible for the 61st through the 90th days of inpatient hospital services used during each benefit period.

The year in which the patient's benefit period begins determines the coinsurance amount applicable in his case. For example, where a benefit period begins in 1980 the coinsurance amount for the 61st through the 90th days is $45 even though the benefit period extends into 1981. In the unusual case where the actual charge to the beneficiary is less than the applicable coinsurance amount, the coinsurance is the actual charge per day. These rules also apply to the lifetime reserve days, coinsurance and the extended care coinsurance.

The following chart shows the inpatient hospital coinsurance amounts for benefit periods beginning in each year since 1974:

11195. Part A Blood Deductible

(There is also a Part B blood deductible which applies on a calendar year basis (see CM 11377.) The Part A and Part B blood deductibles are applied separately.) (a) Definition

The blood deductible applies only to whole blood and packed red cells. The term whole blood means human blood from which none of the liquid or cellular components have been removed. Where packed red cells are furnished, a unit of packed red cells is considered equivalent to a pint of whole blood. Other components of blood such as platelets, fibrinogen, plasma, gamma globlin, and serum albumin are not subject to the blood deductible. However, these components of blood are covered as biologicals.

(b) Blood Deductible

Program payment may not be made for the first three pints of whole blood or quivalent units of packed red cells received by a beneficiary in a benefit period. However, payment may be made for blood processing beginning with the first pint or unit in a benefit period. The blood deductible is in addition to any other appilcable deductible and coinsurance amounts for which the patient is responsible.

To be covered a Part A service and count toward the blood deductible, the blood must be furnished on a day which counts as a day of inpatient hospital services or

extended care services. Thus, blood is not covered under Part A and does not count toward the Part A blood deductible when furnished to an inpatient after he has exhausted his benefit days in a benefit period, or where the individual has elected not to use lifetime reserve days. However, where the patient is discharged on his first day of entitlement, the provider is permitted to submit a billing form with no accommodation charge, but with ancillary charges including blood.

When the beneficiary is subject to the blood deductible, he has the option of replacing the blood on a pintfor-pint or unit basis, or paying the provider's charges for the unreplaced pints.

When a beneficiary elects to replace deductible pints or units, it is considered replaced if the patient or someone else, e.g., a volunteer blood bank organization, replaces the blood on his behalf. For Medicare purposes, replacment is made on a pint-forpint or unit basis. Although a provider is free to persuade a beneficiary to arrange for donation of more blood than was required to meet the deductible provisions, no charge may be made to a beneficiary who does not comply with the request if he has replaced, or arranged to be replaced, on a pint-for-pint or unit basis, each of the blood deductible pints he received.

Where more blood is donated on behalf of the beneficiary than is needed for full replacement on a pint-for-pint or unit basis, the value of the excess blood is not deducted from the amount payable to the provider. However, such donations would tend to reduce the cost of blood to the provider. Where a provider accepts blood donated in advance for or by a beneficiary in anticipation of need, such donations are considered as replacement for any deductible pints or units subsequently furnished him in the future.

(c) Obligation of the Beneficiary to Pay for or Replace Deductible Blood

A beneficiary who receives blood (or packed red cells) which is subject to the blood deductible, has the option of replacing the blood or paying the provider's charges for the unreplaced pints.

(1) PROHIBITION ON CHARGING FOR REPLACED DEDUC. TIBLE BLOOD

A beneficiary may not be charged for deductible blood which he has replaced, or arranged to replace He has made arrangements for replacement, and therefore cannot be charged for deductible blood, if he, another individual or a group or organization acting on his behalf, e.g., a blood assurance plan, offers replacement pints or units, whether or not the provider accepts the offer. A provider may not charge a beneficiary because its policy is not to accept blood from a particular organization which has offered to replace blood on the beneficiary's behalf. However, a provider is not barred from charging a beneficiary for deductible blood, if there is a reasonable basis for believing replacement blood offered by or on behalf of the beneficiary would endanger the health of either the donor or a recipient.