405.2074 Reconsidered determination. 405.2075 Submission of evidence.

405.2076 Notice and effect of reconsidered determination.

405.2077 Hearing; right to hearing; time and manner of filing request for hearing.

405.2078 Postponement of effective date of initial determination.

405.2079 Parties to the hearing. 405.2080 Hearing officer.

405.2081 Disqualification of hearing officer.

405.2082 Location of hearing. 405.2083 Notice of hearing.

405.2084 Conduct of hearing. 405.2085 Record of hearing. 405.2086 Authority of hearing officer. 405.2087 Hearing decision and notice. 405.2088 Effect of hearing decision. 405.2089 Appointment of representative. 405.2090 Authority of representative. 405.2091 Reopening of initial or reconsid

ered determination and decision of a hearing officer.

405.2092 Notice of reopening and revision.

Subpart U-Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services

405.2100 Scope of subpart.

405.2101 Objectives of end-stage renal disease (ESRD) program. 405.2102 Definitions.

405.2110 Designation of ESRD network

areas.

405.2111 Designation of network coordinating councils.

Sec.

405.2112 Designation of ESRD networks. 405.2113 Medical review board. 405.2114 Relationship of ESRD networks

to health care review organizations and to health service planning organizations. 405.2120 Minimal utilization rates: general. 405.2121 Basis for determining minimal utilization rates.

405.2122 Types and duration of classification according to utilization rates. 405.2123 Reporting of utilization rates for initial classification.

405.2124 Calculation of utilization rates for comparison with minimal utilization rates(s) and notification of status. 405.2130 Condition: Minimal utilization rates.

405.2131 Condition: Provider status: Renal transplantation center or renal dialysis

center.

405.2132 Condition: Fulfillment of service needs in network.

405.2133 Condition: Furnishing data and information for ESRD program administration.

405.2134 Condition: Membership in a network.

405.2135 Condition: Compliance with Federal, State, and local laws and regulations.

405.2136 Condition: Governing body and

management.

405.2137 Condition: Patient long-term program and patient care plan.

405.2138 Condition: Patients' rights and re

sponsibilities.

405.2139 Condition: Medical records. 405.2140 Condition: Physical environment. 405.2160 Condition: Affiliation agreement or arrangement.

405.2161 Condition: Director of a renal dialysis facility or renal dialysis center. 405.2162 Condition: Staff of a renal dialysis facility or renal dialysis center. 405.2163 Condition: Minimal service requirements for a renal dialysis facility or renal dialysis center.

405.2170 Condition: Director of a renal transplantation center.

405.2171 Condition: Minimal service requirements for a renal transplantation center.

EDITORIAL NOTE: Part 405 of title 20 was transferred into title 42 at 42 FR 52826, September 30, 1977. As a result of the transfer, all section numbers in this part are remaining the same and now appear as 42 CFR Part 405.

NOTE: Nomenclature changes affecting this Part 405 appear at 38 FR 3597, Feb. 8, 1973; 38 FR 26718, Sept. 25, 1973; 41 FR 51588, Nov. 23, 1976; 42 FR 65113, Dec. 29, 1977.

Subpart A-Hospital Insurance Benefits

AUTHORITY: Secs. 1102, 1801-1817, 1866, 1871, 49 Stat. 647, as amended, 79 Stat. 291301, 314; 79 Stat. 331; 42 U.S.C. 1302, 1395 et seq.

§ 405.101 Hospital insurance benefits; general.

(a) 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, or to him (for certain hospital services) subject to the conditions and limitations set out in this Part 405 and in the Act, for:

(1) Inpatient hospital services, posthospital extended care services, and posthospital home health services furnished to him during any month for which he meets such conditions for entitlement to hospital insurance benefits; and

(2) Outpatient hospital diagnostic services furnished to him during any month before April 1968, for which he meets such conditions for entitlement to hospital insurance benefits. Effective with services furnished on or after April 1, 1968, coverage of outpatient hospital diagnostic services is transferred from this Subpart A to the supplementary medical insurance benefits plan described in Subpart B of this Part 405.

(b) Except where payment may be made to the individual for certain hospital services (see §§ 405.156 and 405.157), payment for the services covered under the hospital insurance benefits program is made to the institution or agency eligible to receive payment rather than to the individual to whom the services are furnished.

[34 FR 11201, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.102 Hospital insurance benefits for individuals age 65 or over.

(a) Conditions of entitlement. An individual is entitled to hospital insurance benefits under the provisions described in this Subpart A if such individual has attained age 65 and:

(1) Is entitled to monthly insurance benefits under section 202 of the Social Security Act as described in Subpart D of 20 CFR Part 404; or

(2) Is a "qualified railroad retirement beneficiary" as described in paragraph (b) of this section; or

(3) Is deemed entitled to monthly insurance benefits under section 202 of the Social Security Act, solely for purposes of entitlement to hospital insurance benefits, by meeting the requirements prescribed in § 405.103.

(b) Qualified railroad retirement beneficiary. For purposes of this Part 405, the term "qualified railroad retirement beneficiary" means an individual whose name has been certified to the Social Security Administration by the Railroad Retirement Board under section 7(d) of the Railroad Retirement Act of 1974. An individual shall cease to be a qualified railroad retirement beneficiary at the close of the month preceding the month which is certified by the Railroad Retirement Board as the month in which he ceases to meet the requirements of section 7(d) of the Railroad Retirement Act of 1974.

(c) Beginning of coverage. 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 of paragraph (a) of this section.

(d) End of coverage—(1) General. An individual's entitlement to hospital insurance benefits under paragraph (a) of this section ends with whichever occurs first:

(i) The last day of the month in which he dies; or

(ii) 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 Social Security Act;

(B) of section 7(d) of the Railroad Retirement Act of 1974, if qualified for hospital insurance benefits solely as a qualified railroad retirement beneficiary; or

(C) of the transitional provisions on eligibility for hospital insurance benefits (see § 405.103) because such individual has become entitled to monthly benefits under section 202 of the

Social Security Act or has been certified as a qualified railroad retirement beneficiary.

(2) Deemed entitlement in the month of death. For purposes of paragraph (d)(1) of this section, an individual will be deemed to have been entitled to a monthly insurance benefit under section 202 of the Social Security Act, or to have been a qualified railroad retirement beneficiary, for the month in which he died if he would have been entitled to a monthly insurance benefit under section 202 of the Act, or would have been a qualified railroad retirement beneficiary, for such month had he died in the next month. [40 FR 24357, June 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977)

§ 405.103 Transitional provisions for entitlement of aged uninsured individuals to hospital insurance benefits. (a) Requirements. Unless excluded under the provisions of paragraph (b) of this section, an individual age 65 or over will be deemed entitled to monthly insurance benefits under section 202 of the Social Security Act, solely for purposes of entitlement to hospital insurance benefits (see § 405.102(a)(3)), if such individual:

or

(1) (i) Attained age 65 before 1968,

(ii) Attained age 65 after 1967 and has not less than three quarters of coverage (as defined in Subpart B of 20 CFR Part 404 or in section (5)(1) of the Railroad Retirement Act of 1937), whenever acquired, for each calendar year after 1966 and before the year he attained age 65;

(2) Is not entitled to hospital insurance benefits as provided in § 405.102(a)(1) and would not be entitled to such benefits upon filing an application for monthly insurance benefits under section 202 of the Social Security Act;

(3) Is not certifiable as a qualified railroad retirement beneficiary (see § 405.102(a)(2));

(4) Is a resident of the United States (for definition of United States see 20 CFR 404.2(c)(6)), and

or

in the United States continuously during the 5 years immediately preceding the month in which he files his application required under paragraph (a)(5) of this section; and

(5) Has filed an application for entitlement to hospital insurance benefits under § 405.102(a)(3). Such application must be filed no earlier than 3 months before the first month in which the individual meets the requirements of paragraphs (a) (1), (2), (3), and (4) of this section. An application filed within 12 months after any month in which these requirements are met will be deemed to have been filed in such month.

(b) Individuals not deemed entitled. An individual may not be deemed entitled to monthly insurance benefits under section 202 of the Social Security Act, for purposes of § 405.102(a)(3), if either of the following exists:

(1) He was covered by an enrollment in a health benefits plan under the Federal Employees Health Benefits Act of 1959 as of February 16, 1965, or as of the first day of the first month in which he meets the requirements set forth in paragraph (a) of this section, or (ii) he could have been so covered for such first month if he or some other person had availed himself of an opportunity to enroll in a health benefits plan under the Federal Employees Health Benefits Act of 1959 and to continue such enrollment, provided that he or such other person was a Federal employee at any time after February 15, 1965. This exclusion shall not apply in the case of any individual for the month (or any month thereafter) in which

(i) His coverage under such health benefits plan ceases (or would have ceased if he had had such coverage),

(ii) Such cessation of coverage was by reason of his or some other person's separation from Federal service, and

(iii) He, or such other person, was not (or would not have been) eligible to continue such coverage after such separation.

(2) Before the first month in which

(ii) Is an alien lawfully admitted for permanent residence who has resided

graph (a) of this section, he has been convicted of any offense under chapter 37 (relating to espionage and cen

sorship), or chapter 115 (relating to treason, sedition, and subversive activities), or chapter 105 (relating to sabotage) of title 18 of the United States Code; or section 4 (relating to conspiracy to establish dictatorship), 112 (relating to espionage or sabotage), or 113 (relating to individuals assisting others wanted in connection with espionage or sabotage) of the Internal Security Act of 1950, as amended.

[40 FR 24358, June 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.104 Entitlement to hospital insurance benefits based on end-stage renal disease.

(a) Conditions of entitlement. An individual is eligible for hospital insurance benefits based on end-stage renal disease if he:

(1) Has not attained age 65; and

(2) Is either-(i) Fully or currently insured (as such terms are defined in section 214 of the Act and Subpart B of 20 CFR Part 404) or would be fully or currently insured if his service as an employee (as defined in the Railroad Retirement Act of 1974) after December 31, 1936, were included in the term "employment" as defined in the Social Security Act, or

(ii) Entitled to monthly insurance benefits under title II of the Social Security Act or to an annuity under the Railroad Retirement Act of 1974, or

(iii) The spouse or dependent child of a person who meets the requirements in paragraph (a)(2) (i) or (ii) of this section; and

(3) Is medically determined to have end-stage renal disease as defined in paragraph (d)(1) of this section.

(b) Beginning of coverage. An eligible individual as defined in paragraph (a) of this section is entitled to hospital insurance benefits beginning with whichever of the following is the latest:

(1) July 1, 1973; or

(2) The first day of whichever first

occurs

(i) The month in which he receives a renal transplant, or

(ii) The month prior to the month in which he receives a renal transplant if, in such prior month, he is hospitalized in preparation for and in anticipation of such surgery, or

(iii) The third calendar month after the month in which he begins a course of dialysis; or

(3) The first month in which he meets the requirements of paragraph (a) of this section.

(c) End of coverage. An individual's entitlement to hospital insurance benefits based on end-stage renal disease ends with the last day of whichever of the following first occurs:

(1) The 12th month after the month in which he receives a kidney transplant or his course of dialysis otherwise terminates, unless on or before the last day of such 12th month the individual again requires a course of dialysis or another kidney transplant;

or

(2) The month in which he dies.

(d) Definitions—(1) End-stage renal disease. An individual who is medically determined to have chronic renal disease and who requires hemodialysis or renal transplantation for such disease has "end-stage renal disease." Endstage renal disease is that stage of kidney impairment which is irreversible, cannot be controlled by conservative management alone, and requires dialysis or kidney transplantation to maintain life.

(2) "Child" and "spouse" defined. An individual is the child or spouse of a person, for purposes of paragraph (a)(2)(iii) of this section, if the individual is so related to that person that he meets the relationship requirements set forth in Subpart L of 20 CFR Part 404 for entitlement, respectively, to child's insurance benefits or to wife's, husband's, widow's, widower's, or mother's insurance benefits under title II on that person's earnings record, whether or not the relationship has continued long enough for such individual to qualify for such benefits. Notwithstanding the foregoing, an individual who qualifies as a spouse by virtue of 20 CFR 404.1105 must meet the duration of relationship requirements prescribed therein.

(3) Dependency of a child. For purposes of paragraph (a)(2)(iii) of this section, the child of a person is that person's "dependent child" if on the first day he has end-stage renal disease he is unmarried and meets the dependency requirements set forth in 20