SUBCHAPTER C-MEDICAL ASSISTANCE PROGRAMS State organization-Medical Assistance Programs. 449 Administration of medical assistance programs...... Interrelations of Medical Assistance Programs with other programs or agencies........................................ SUBCHAPTER D─PROFESSIONAL STANDARDS REVIEW ....... SUBCHAPTER A-[RESERVED] SUBCHAPTER B-MEDICARE PROGRAMS 405.101 Hospital insurance benefits; gener- 405.102 Hospital insurance benefits for in- 405.103 Transitional provisions for entitle- ment of aged uninsured individuals to 405.104 Entitlement to hospital insurance benefits based on end-stage renal dis- 405.105 Hospital insurance entitlement based on entitlement to disability insur- 405.106 Premium hospital insurance. 405.110 Inpatient hospital services; scope 405.111 Inpatient hospital services; benefit limitation during first spell of illness- inpatient of participating tuberculosis or 405.112 Inpatient hospital services; services considered for purposes of benefit limi- 405.113 Inpatient hospital services; deduct- 405.114 Inpatient hospital services; whole 405.115 Inpatient hospital services; coin- 405.116 Inpatient hospital services; de- 405.118 Election not to use lifetime reserve 405.119 Revocation of election. vices; services considered for purposes of limitation on days of coverage. 405.123 Posthospital extended care ser- vices; whole blood cost deductible. 405.124 Posthospital extended care ser- 405.125 Extended care services; defined. 405.126 Posthospital extended care; level 405.127 Posthospital extended care; skilled nursing and rehabilitation services. 405.128a Posthospital extended care; need for institutionalization; "practical 405.130 Posthospital home health services; 405.131 Posthospital home health services; 405.133 Post-hospital extended care and post-hospital home health services; pre- 405.141 Outpatient hospital diagnostic ser- 405.142 Outpatient hospital diagnostic ser- 405.144 Outpatient hospital diagnostic ser- vices; diagnostic study defined. 405.145 Outpatient hospital diagnostic ser- 405.150 Payment for services furnished; 405.151 Payment for services furnished; de- termination of amount payable based on 405.152 Payment for services furnished; nonparticipating hospital furnishing 405.153 Payment for services; hospital out- 405.154 Payment for services furnished; 405.155 Payment for services furnished; providers obligated to furnish services at 405.156 Payment to entitled individual for services furnished by a nonparticipating hospital; inpatient admission before Jan- 405.157 Payment to entitled individual for emergency services furnished after 1967. 405.158 Payment to entitled individual; de- termination of amount payable for ser- vices furnished by a nonparticipating 405.160 Payment to participating hospital for inpatient hospital services; condi- 405.161 Payment for inpatient hospital ser- vices; furnished after 90- or 150-day 405.162 Prohibition against payment for inpatient hospital services furnished after utilization review finding that fur- ther services are not medically neces- 405.163 Prohibition against payment for inpatient hospital services furnished after 20th consecutive day by a hospital tended care services; conditions. 405.166 Prohibition against payment for posthospital extended care services fur- nished after a utilization review finding that services are not medically neces- 405.167 Prohibition against payment for services furnished by a facility which fails to make timely utilization review. 405.170 Payment for posthospital home 405.175 Payment to participating hospital for outpatient hospital diagnostic ser- 405.180 No payment for services furnished to an alien before the first full calendar 405.181 Individual convicted of subversive activities; effect on entitlement. 405.191 Emergency services; finding that 405.231 Medical and other health services; 405.232 Medical and other health services; conditions, limitations, and exclusions. 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 405.237 Home health services; items and 405.238 Home health services; "visits" de- 405.239 Option available to patients under a home health plan who require phys- ical therapy or speech therapy services. 405.240 Payment of supplementary medi- cal insurance benefits; amounts payable. 405.241 Payment of supplementary medi- cal insurance benefits; election by group-practice prepayment plan as to method of determining amount of pay- 405.243 Psychiatric services limitation; ex- penses incurred for physician services. 405.244 Incurred expenses; expenses ex- cluded from total expenses or not con- sidered for purposes of the deductibles. 405.245 The supplementary medical insur- 405.246 Supplementary medical insurance 405.249 Payment to a nonparticipating hospital furnishing emergency outpa- 405.250 Procedures for payment; medical and other health services furnished by participating provider; home health ser- 405.250a Outpatient physical therapy and speech pathology services furnished by participating provider; plan of treat- 405.251 Procedures for payment; medical and other health services furnished by other than a participating provider. Sec. 405.311 Nonreimbursable expenses; individ ual has no legal obligation to pay for items or services. 405.312 Nonreimbursable expenses; items or services paid for by governmental entity. 405.313 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 beneficiaries' household. 405.315a Nonreimbursable expenses; Items or services furnished by excluded provider or other person. 405.315b Establishment of program review teams. 405.316 Nonreimbursable expenses; payment for services made under workmen's compensation law. 405.317 Effect of workmen's compensation payment. 405.318 Responsibility of the individual workmen's compensation concerning payment. where there is a possibility of workmen's compensation coverage. 405.320 Effect of lump-sum settlement and final release. 405.321 Apportionment of a lump-sum compromise settlement of a workmen's compensation claim. 405.330 Payment for certain nonreimbursable expenses. 405.331 Liability for certain noncovered items or services. 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. 405.359 Liability of certifying or disbursing officer. 405.370 Suspension of payments to provid ers of services and other suppliers of services. 405.371 Proceeding for suspension. 405.372 Submission of evidence and notification of administrative determination to suspend. 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 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. 405.451 Cost related to patient care. 405.452 Determination of cost of services to beneficiaries. 405.453 Adequate cost data and cost finding. 405.454 Payments to providers. 405.455 Amount of payments where customary charges for services furnished are less than reasonable cost. 405.460 Limitations on coverage of costs. 405.461 Limitations on coverage of costs; charges to beneficiaries where cost limits are applied to services. 405.465 Determining reimbursement for certain physician and medical school 405.503 Determining customary charges. 405.504 Determining prevailing charges. 405.505 Determination of "locality." 405.506 Charges higher than customary or prevailing charges. 405.507 Illustrations of the application of the criteria for determining reasonable charges. 405.508 Determination of comparable cir cumstances; limitation. 405.512 Carriers' procedural terminology and coding systems. 405.520 Reimbursement for services of interns, residents and supervising physicians; general. 405.521 Services of attending physicians supervising interns and residents. 405.522 Interns' and residents' services in approved teaching programs. 405.523 Interns' and residents' services not in approved teaching programs. 405.524 Interns' and residents' services outside the hospital. 405.525 Basis of reimbursement to provid ers under the health insurance program for services of interns and residents. 405.541 Criteria for determination of rea sonable charges for nonprovider renal dialysis facility services. 405.542 Criteria for determination of rea sonable charges for physicians' services rendered to renal dialysis patients. 405.543 Criteria for determination of reasonable charges for physicians renal transplantation services. Sec. 405.544 Criteria for determination of reasonable charges for durable medical equipment and supplies for home dialysis. Subpart F—Agreements, Elections, Contracts, Nominations, and Notices 405.601 Scope of subpart. 405.602 Provider agreements; general. 405.603 Acceptance of agreement by Secretary; bankruptcy and insolvency. 405.604 Term agreements with skilled nursing facilities. 405.605 Provider of services; scope of term. 405.606 Acceptance of provider as a participant. 405.607 Essentials of agreements with providers of services. 405.608 Allowable charges; deductible, coinsurance and copayment. 405.609 Allowable charges; whole blood costs. 405.610 Allowable charges; noncovered and partially covered items or services; prepayment requirements and other charges. 405.612 Compliance with procedural and other requirements; individual's refusal to execute request for payment. 405.613 Termination by provider of services. 405.614 Termination by the Secretary. 405.615 Applicability of termination. 405.616 Reinstatement of provider as participant after termination. 405.617 Limitation; failure to make timely utilization review. 405.618 Disposition of incorrect collections. 405.619 Notice of charges and collections by a provider of services. 405.620 Return or other disposition of moneys incorrectly collected. 405.621 Appropriate time limits within which provider action must be taken. 405.622 Incorrect collections; payment of offset amounts to beneficiary or other person. 405.625 Transfer of provider ownership; general. 405.626 Change of ownership; participating in the health insurance program. 405.640 Notice of determination by the Secretary rescinding approval of coverage of services of independent laboratory or supplier of portable X-ray services. 405.651 Nomination of agency or organization as "intermediary"; contractual undertakings with intermediaries. 405.652 Nomination procedure. 405.653 Nomination by providers of services; nonmembers or nonconcurring members of a group or association. 405.654 Election to deal through a nominated agency or organization or to deal directly with the Secretary. 90-214 O-78-2 |