Page images
PDF
EPUB
[blocks in formation]

405.1033 Condition of participation-Emergency service or department. 405.1034 Condition of participation Social work department.

405.1035 Condition of participation-Utilization review plan.

405.1036 Special rules and exceptions applying to psychiatric and tuberculosis hospitals.

405.1037 Condition of participation-Special medical record requirements for psychiatric hospitals.

405.1038 Condition of participation-Special staff requirements for psychiatric hospitals.

405.1039 Condition of participation-Special medical record requirements for tuberculosis hospitals.

405.1040 Condition of participation-Special staff requirements for tuberculosis hospitals.

Subparts K through L-[Reserved]

Subpart M-Conditions for Coverage of Services of Independent Laboratories

405.1301 Conditions for coverage of services of independent laboratories; general.

405.1302 Conditions for coverage of services;

[blocks in formation]

405.1315 Condition clinical laboratory, technical personnel.

405.1316 Condition

[blocks in formation]

records, equipment, and fs-
cilities.

Subpart A-Hospital Insurance
Benefits

AUTHORITY: The provisions of this Subpart A issued under secs. 1102, 1801-1817, 1871, 49 Stat. 647, as amended, 79 Stat. 291-301; 79 Stat. 331; 42 U.S.C. 1302, 1395 et seq.

SOURCE: The provisions of this Subpart A appear at 31 F.R. 10116, July 27, 1966, unless otherwise noted. Correction noted at 32 FR. 136, Jan. 7, 1967.

[blocks in formation]

An individual who meets the conditions for entitlement to hospital insurance benefits provided under part A of title XVIII of the Act is eligible to have payment made on his behalf, subject to the conditions and limitations set out in this Part 405 and in the Act, for inpatient hospital services, posthospital extended care services, posthospital home health services, and outpatient hospital diagnostic services furnished to him during any month for which he meets such conditions for entitlement to hospital insurance benefits. Payment for the services covered under the hospital insurance benefits program is made to providers of services eligible to receive payment rather than to the individual to whom the services are furnished.

§ 405.102 Conditions for entitlement to hospital insurance benefits.

An individual is entitled to hospital insurance benefits under the provisions described in this Subpart A if such individual either:

(a) Has attained age 65, and either is entitled to monthly insurance benefits under section 202 of the Act (see Subpart D of Part 404 of this chapter) or is a qualified railroad retirement beneficiary;

or

(b) Qualifies under the transitional provisions of section 103 of the Social Security Amendments of 1965. (See § 404.370 of Part 404 of this chapter.) § 405.103 Duration of entitlement to hospital insurance benefits.

(a) An individual is entitled to hospital insurance benefits beginning with the first day of the first month after June 1966 for which he meets the conditions described in § 405.102; except that no

payment may be made for posthospital extended care services furnished before January 1967, and that no payment may be made for posthospital extended care services or posthospital home health services unless the discharge from the hospital required to qualify such services for payment under this Subpart A occurred after June 30, 1966, or, on or after the first day of the month in which he attains age 65, whichever is later.

(b) (1) An individual's entitlement to hospital insurance benefits ends:

(i) With the last day of the month in which he dies, or

(ii) With the last day of the month before the month he no longer meets the requirements:

(a) For entitlement to monthly benefits under section 202 of the Act;

(b) of section 21 of the Railroad Retirement Act of 1937, if qualified for hospital insurance benefits solely as a railroad retirement beneficiary;

(c) of the transitional provisions on eligibility for hospital insurance benefits (see § 404.370 of Part 404 of this chapter) because such individual has become eligible for monthly benefits under section 202 of the Act.

(2) Entitlement to hospital insurance benefits, if terminated for reason other than death, may be regained by the individual by filing an application for such benefits and meeting any of the conditions specified in § 404.367 of Part 404 of this chapter.

§ 405.110 Inpatient hospital services; scope of benefits.

(a) Benefits. An individual who meets the requirements set forth in § 405.102 is eligible to have payment made on his behalf to a participating hospital (see Subpart J of this Part 405 and § 405.150), subject to the conditions and limitations contained in this Part 405 and title XVIII of the Act, for inpatient hospital services (see § 405.115) furnished to him for up to 90 days during any spell of illness (see Subpart R of this part). (In the case of emergency inpatient hospital services, payment may also be made to certain nonparticipating hospitals-see § 405.152.)

(b) Deductible and coinsurance amounts. Payments for inpatient hospital services furnished during any spell of illness (see Subpart R of this part) is reduced by the amount of the applicable deductibles (see §§ 405.113 and 405.114) and, in addition, by any applicable coinsurance amount (see § 405.115).

(c) 90-day benefit limitation for spell of illness. No payment under this section for inpatient hospital services furnished an individual during any spell of illness (see Subpart R of this part) may be made for any such services furnished to him after the 90th day such services have been furnished to him during such spell of illness (see § 405.161 for exception).

(d) Lifetime maximum on inpatient psychiatric hospital services. Notwithstanding the preceding provisions of this section, no payment for inpatient psychiatric hospital services (see Subpart J of this part) may be made for any such services furnished an individual after the 190th day such services have been furnished to him during his lifetime. § 405.111 Inpatient hospital services; determining the 90-day benefit limitation-inpatient of a psychiatric or tuberculosis hospital.

If an individual is an inpatient of a qualified psychiatric or tuberculosis hospital as defined in Subpart J of this Part 405 on the first day for which he is entitled to hospital insurance benefits (see § 405.103), the days on which he has already been an inpatient of such hospital in the 90-day period immediately before such day are deducted from the 90 days of inpatient hospital services for which he is entitled to have payment made during his first spell of illness; however, such days preceding entitlement are not counted in determining the 190-day lifetime limit on inpatient psychiatric hospital services (see § 405.110(d)) and are not counted in determining the first day for which the coinsurance amount is deducted from payment for inpatient hospital services (see 405.115).

EXAMPLE 1: B is an inpatient of a psychiatric hospital on July 1, 1966, the first day for which he is entitled to hospital insurance benefits, and has been an inpatient of such hospital for the 2 years immediately preceding July 1. 1966. No payment will be made for inpatient hospital services furnished to B during that spell of illness.

EXAMPLE 2: C entered a tuberculosis hospital on August 12, 1966, and is still an inpatient of such hospital 50 days later on October 1, 1966, the first day for which he is entitled to hospital insurance benefits. Payment may be made for up to 40 days of inpatient hospital services since C had been an inpatient of the tuberculosis hospital for 50 days preceding the first day for which he was entitled to hospital insurance benefits. However, the 50 days preceding October 1,

1966, is not counted in determining the 60 days of coverage and, therefore, the COinsurance amount (see § 405.115) is not applicable with respect to any payment for the 40 days of services for which C is entitled to have payment made on his behalf.

EXAMPLE 3: D is a patient of an institution that is not a qualified psychiatric hospital on August 1, 1966, the first day for which he is entitled to hospital insurance benefits, and has been a patient of the nonqualifying hospital for the one year preceding August 1, 1966. Several days later D is transferred to a participating psychiatric hospital. Payment may be made for up to 90 days of inpatient hospital services after such transfer since inpatient hospital services received in a nonqualifying hospital in the period preceding entitlement are not considered for the purposes of determining the 90-day spell of illness limitation.

§ 405.112 Inpatient hospital services; services considered for purposes of 90-day and 190-day limitations.

For purposes of determining the 90day benefit limitation described in § 405.110 (c), or § 405.111, or the 190-day benefit limitation described in § 405.110 (d), inpatient hospital services are taken into account only if:

(a) Payment is made with respect to such services: or

(b) Payment would be made for such services except for failure to comply with the request and certification requirements (see § 405.160).

§ 405.113 Inpatient hospital services; deductible.

(a) Spell of illness beginning prior to 1969. The amount payable for inpatient hospital services (see §§ 405.150 and 405.151) furnished to an individual during any spell of illness (see Subpart R of this part) beginning prior to 1969 is reduced (but not below zero) by an amount equal to the lesser of:

(1) $40; or

(2) The charges imposed with respect to such services or the customary charges for such services, whichever is greater.

(b) Spell of illness beginning after 1968. Between July 1 and October 1 of 1968, and of each year thereafter, the Secretary shall determine the amount of the inpatient hospital deductible which shall be applicable in the case of any spell of illness (see Subpart R of this part) beginning during the succeeding calendar year.

§ 405.114

Inpatient hospital services; whole blood cost deductible. Where all or part of the first 3 pints of whole blood furnished an individual by a provider of services during a spell of illness is furnished him as part of inpatient hospital services, the amount payable for such services is reduced by the cost of the first 3 pints of whole blood furnished him as part of such services during that spell of illness.

EXAMPLE: During the same spell of illness, B receives the following services: inpatient hospital service in hospital X from July 1 to July 10, 1967: posthospital extended care services in an extended care facility from July 15 to July 25, 1967: inpatient hospital services in hospital Y from August 15 to August 25, 1967. During this spell of illness. B is furnished 6 pints of whole blood; 2 pints in hospital X, 2 pints in the extended care facility, and 2 pints in hospital Y. The whole blood deductible is applicable to the cost of the 2 pints of whole blood furnished in hospital X, and to the cost of 1 pint furnished in the extended care facility, since these are the first 3 pints of whole blood furnished B by providers of services during the spell of illness. It is not applicable to the cost of any of the whole blood furnished in hospital Y.

§ 405.115 Inpatient hospital services;

coinsurance amount.

(a) In any case in which an individual is furnished inpatient hospital services for more than 60 days during a spell of illness (see Subpart R of this Part 405) beginning before 1969, the amount payable (see §§ 405.150 and 405.151), for the inpatient hospital services furnished after such 60th day during such spell of illness, is reduced by a coinsurance amount equal to $10 for each day, after the 60th day and before the 91st day, on which he is furnished such services.

(b) Since the inpatient hospital services coinsurance amount is set by law at one-fourth of the inpatient hospital services deductible, the coinsurance amount applicable for spells of illness beginning after 1968 will reflect any adjustment made in the deductible (see § 405.113 (b)).

§ 405.116 Inpatient hospital services;

defined.

(a) Included services. Subject to the conditions, limitations, and exceptions in the succeeding paragraphs of this section, the term "inpatient hospital services" means the following items and services furnished by a qualified hospital, except as provided in paragraph (e) of

this section (including a psychiatric hospital or a tuberculosis hospital) to an inpatient of such hospital:

(1) Bed and board;

(2) Nursing services and other related services;

(3) Use of hospital facilities;
(4) Medical social services;

(5) Drugs, biologicals, supplies, appliances and equipment;

(6) Certain other diagnostic or therapeutic items or services; and

(7) Medical or surgical services provided by certain interns or residents-intraining.

(b) Bed and board. The reasonable costs are payable in full for hospital room and board furnished an individual in accommodations containing from two to four beds, or in hospitals in which all accommodations are on a ward basis and charges are not related to the number of beds in a room. The reasonable cost of private accommodations is covered in full only where their use is medically indicated, ordinarily only when a patient's condition requires him to be isolated. Where private accommodations are furnished for a patient's comfort, the amount payable under this Subpart A may not exceed the reasonable cost of accommodations containing from two to four beds. Where accommodations less expensive than accommodations containing from two to four beds are furnished a patient and the use of these accommodations was neither at the request of the patient nor for a reason consistent with the purposes of the Act, the amount payable for bed and board is the reasonable cost of two to four bed accommodations minus the difference between the customary charges for such accommodations and the customary charges for the accommodations furnished.

(c) Nursing services and other related medical services; medical social services; use of hospital facilities. Nursing services and other related services, use of hospital facilities, and medical social services, are considered as inpatient hospital services only if ordinarily furnished by the hospital for the care and treatment of inpatients. The services of a private-duty nurse or other private-duty attendant are excluded from the definition of inpatient hospital services.

(d) Drugs, biologicals, supplies, appliances, and equipment. Drugs, biologicals, supplies, appliances, and equipment (as defined in Subpart R of this Part

405) are included as inpatient hospital services only if furnished to an inpatient for use in the hospital and if ordinarily furnished by such hospital for the care and treatment of inpatients.

(e) Diagnostic or therapeutic items or services. Diagnostic or therapeutic items or services other than those provided for in paragraphs (c), (d), and (f) of this section, are considered as inpatient hospital services if furnished by the hospital, or by others under arrangements made by the hospital under which the billing for such services is made through such hospital and if such services are of a kind ordinarily furnished to inpatients either by such hospital or by others under such arrangements (see Subpart R of this part for definition of "arrangement").

(f) Medical or surgical services provided by a physician, intern, resident, or resident-in-training. Medical or surgical services provided in a hospital by a physician or by a resident or intern, are excluded from the definition of "inpatient hospital services" unless such services are provided by an intern or resident-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association; or in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association; or in the case of a hospital or osteopathic hospital, by an intern or resident-in-training in the field of dentistry under a teaching program approved by the Council on Dental Education of the American Dental Association.

§ 405.120 Posthospital extended care services; scope of benefits.

(a) Benefits and conditions for entitlement. An individual who meets the requirements described in § 405.102, is eligible to have payment made on his behalf to a participating extended care facility (see § 405.150) for up to 100 days of extended care services (8 405.124) furnished to him in a spell of illness if such extended care services are furnished him after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days (as defined in paragraph (c) of this section). An individual is deemed to have transferred from a hospital if he is admitted to the extended care facility within 14 days (as defined in paragraph (d) of this section) after his discharge from such hospital

and such discharge occurred on or after the first day of the month in which the individual attained age 65, or after June 30, 1966, whichever is later.

(b) Services for which payment is not made. (1) No payment may be made for any posthospital extended care services furnished an individual on any day after the 100th day such services have been furnished to him during a spell of illness.

(2) Where an individual who has been furnished posthospital extended care services is discharged from the extended care facility, no payment may be made for any subsequent extended care services furnished during such spell of illness unless he is again hospitalized for at least 3 consecutive days and the other conditions in paragraph (a) of this section are met; however, for purposes of this subparagraph, an individual is not deemed to have been discharged from an extended care facility in which he has been receiving posthospital extended care services, if, within 14 days after discharge therefrom, he is readmitted to the same, or any other, extended care facility.

(c) The 3 consecutive days as a hospital inpatient; defined. The 3-consecutive-day hospital inpatient requirement is a period of 3 consecutive calendar days beginning with the calendar day of admission even if less than a 24-hour day, and ending with the day before the calendar day of discharge. Thus, in determining whether the 3-consecutive-day requirement is met, the day of admission is counted as one day; the day of discharge is not counted as a day; and each intervening day is counted as a single day.

(d) 14-day period; defined. The 14day period referred to in paragraph (a) of this section, for determining whether an individual is deemed to have transferred from a hospital, is the period of 14 consecutive calendar days beginning with the calendar day following the day of discharge from the hospital.

(e) Deductible and coinsurance amount. Payment (see §§ 405.150 and 405.151) for posthospital extended care services is reduced by the coinsurance amount (see § 405.124) for any day on which such services are furnished after the 20th day and before the 101st day, during a spell of illness, and does not include the costs of any part of the first 3 pints of whole blood furnished an individual in a spell of illness (see § 405.123).

[blocks in formation]

services; whole blood cost deductible.

The amount payable (see §§ 405.150 and 405.151) for posthospital extended care services furnished an individual during a spell of illness (see Subpart R of this Part 405) is reduced by an amount equal to the cost of the first 3 pints of whole blood furnished to him as part of such services; except that the deduction provided under this section does not apply to the extent that a deduction for the cost of the first 3 pints of whole blood furnished to him during such spell of illness has been made under § 405.114. § 405.124 Posthospital extended care services; coinsurance amount.

(a) Spell of illness beginning before 1969. (1) In any case in which an individual is furnished posthospital extended care services for more than 20 days during a spell of illness (see Subpart R of this Part 405) beginning before 1969, the amount payable for posthospital extended care services furnished after such 20th day is reduced by a coinsurance amount equal to $5 for each day such services are furnished after the 20th day and before the 101st day on which he is furnished such services during such spell of illness.

(b) Spell of illness beginning after 1968. The posthospital extended care services coinsurance amount applicable for spells of illness beginning after 1968 is one-eighth of the inpatient hosptial services deductible. Therefore, the coinsurance amount applicable for spells of illness beginning after 1968 will reflect any adjustment made in the amount of the inpatient hospital deductible for calendar years after 1968 (see § 405.113(b)).

« PreviousContinue »