and which is required until such time as the patient can obtain a continuing supply, or in cases where it would be unreasonable or impossible from a medical standpoint to discontinue the patient's use of the item at the time of termination of this stay as an inpatient. (For example, tracheostomy or draining tubes, or cardiac valves and cardiac pacemakers.)

(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.

(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 (1) by an intern or resident-in-training under a teaching program approved by the Council or. 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 (2) 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; or (3) for cost reporting periods beginning after December 31, 1972, by an intern or resident-in-training in the field of podiatry under a teaching program approved by the Council on Podiatry Education of the American Podiatry Association.

(g) Services in connection with kidney transplantation. Beginning September 1, 1977, kidney transplantation surgery is covered only if performed in a renal transplantation

center approved under subpart U of this part.

(h) Services in connection with kidney donations. Services furnished in connection with kidney donations are covered if the kidney donation is intended for an individual entitled to Medicare benefits and the services are related to the evaluation or preparation of a potential or actual donor, to the donation of the kidney, or to postoperative recovery services directly related to the kidney donation.

[31 FR 10118, July 27, 1966, as amended at 34 FR 11204, July 3, 1969; 35 FR 9278, June 13, 1970; 39 FR 32328, Sept. 6, 1974; 40 FR 17747, Apr. 22, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 49721, Oct. 24, 1978]

kidney donor services. Notwithstanding any other provisions in this title, there are no deductible or coinsurance requirements with respect to services furnished to an individual in connection with the donation of a kidney for transplant surgery.

[43 FR 49721, Oct. 24, 1978]

§ 405.118 Election not to use lifetime reserve days.

(a) General. An election not to use lifetime reserve days may be made by the beneficiary (or by someone acting on his behalf (see paragraph (e) of this section)) at the time of admission to a hospital or at any time thereafter, subject to the limitations on retroactive elections described in paragraph (c) of this section. A beneficiary will be deemed to have elected not to use his lifetime reserve days to cover inpatient days where the charges for covered services furnished to him on such days are equal to or less than the applicable coinsurance amount. (See § 405.115(b).)

(b) Election made prospectively. Ordinarily, an election not to use reserve days will apply prospectively. If the election is filed at the time of admission to a hospital it may be made effective beginning with the first day of hospitalization, or with any day thereafter. If filed later it may be made effective beginning with any day after the day it is filed.

(c) Retroactive election. A beneficiary may, while he is still in the hospital, or within a period of 90 days following his discharge, execute a retroactive election not to use in his reserve days for inpatient hospital services already furnished to him, provided that (1) the beneficiary or some other person or organization agrees to pay the hospital for the services in question, or (2) the hospital agrees to accept the retroactive election.

Example. Prior to July 1, A had used 90 days of inpatient hospital services in a spell of illness. Beginning July 1, he was hospitalized for 10 days. A was informed of his election right on July 1 at the time of his admission and indicated that he wanted to use his reserve days for that stay. One month after being discharged from the hospital, A informed the hospital that he now wished to save his reserve days for a future stay. A greed to pay the hospital for the services he received during the 10 days of hospitalization and he was permitted to file a retroactive election not to use his reserve days for such stay effective July 1.

(d) Period covered by election. An individual may elect not to use reserve days for only one period of consecutive days in a single hospital stay. If an election (whether made prospectively or retroactively) is made effective beginning with the first day for which reserve days are available, it may be terminated by the individual at any time. Thereafter, the remaining days of his hospital stay are covered under the hospital insurance program to the extent that reserve days are available. Thus, an individual who has private insurance which covers hospitalization beginning with the first day after the first 90 days of benefits have been exhausted may terminate his election as of the first day not covered by the private insurance plan. If an election not to use reserve days is made effective beginning with any day after the first day for which reserve days are available, it must remain in effect until the end of that stay, unless it is revoked as provided in § 405.119.

(e) Election where beneficiary incapacitated. Where a beneficiary is physically or mentally unable to file an election not to use his reserve days, such an election may be filed by any person who is authorized to execute a request for payment on behalf of the

beneficiary for services furnished to him by a provider of services, e.g., a relative (see § 405.1664 for persons authorized to request payment), provided the beneficiary has private insurance which will pay for the hospitalization or some other person agrees to pay the hospital for the services. If the beneficiary does not have private insurance and no other person agrees to pay the hospital for the services, then only the beneficiary's legal representative may file an election on the beneficiary's behalf.

[35 FR 199S2, Dec. 31. 1970. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.119 Revocation of election.

A beneficiary who elected not to use his reserve days for a period of hospitalization may revoke this election while he is still in the hospital or within a period of 90 days following his discharge, provided that a claim has not been filed to have payment made to the hospital under Part B of title XVIII of the Act for medical and other health services (see section 1861(s) of the Act) furnished to him on the hospital days in question by, or under arrangements made by, the hospital. If the beneficiary is incapacitated, any individual who is permitted to sign the request for payment on behalf of the beneficiary for services furnished to him by a provider of services (see § 405.1664 for persons authorized to request payment) may file the revocation on the beneficiary's behalf. The revocation must be submitted to the hospital in writing and should specify the name of the hospital and the admission date of the stay or stays to which it applies. An election not to use reserve days may not be revoked after the beneficiary dies.

[35 FR 19993, Dec. 31, 1970. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.120 Posthospital extended care services; scope of benefits.

(a) Benefits and conditions for entitlement. (1) An individual who meets the requirements described in § 405.102 and who requires the services referred to in §§ 405.126-405.128, is eligible to have payment made on his behalf to a participating skilled nurs

ing facility (see § 405.150) for up to 100 days of extended care services (§ 405.124) furnished to him in a spell of illness if he is admitted to such skilled nursing facility within the time specified in paragraph (d) of this section after his discharge from a hospital in which he was an inpatient for not less than 3 consecutive calendar days (as defined in paragraph (c) of this section) 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.

(2) For purposes of this section the term "hospital," with respect to hospital discharges occurring on or before December 31, 1967, means a hospital (including a psychiatric or tuberculosis hospital) which meets the requirements of paragraphs (1), (2), (3), (4), (5), and (7) of section 1861 (e) of the Act, whether or not it meets the requirements of paragraphs (6) and (8) thereof (see § 405.1001). A nonparticipating psychiatric or tuberculosis hospital need not meet the special requirements which apply to psychiatric and tuberculosis hospitals (see §§ 405.1036-405.1040). With respect to hospital discharges occurring on or after January 1, 1968, such term shall mean a hospital (including a psychiatric or tuberculosis hospital) which meets the requirements described in § 405.152(a) (1).

(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 skilled nursing 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 a skilled nursing facility in which he has been receiving posthospital extended care

services, if, within 14 days (as defined in paragraph (d) of this section) after discharge therefrom, he is readmitted to the same, or any other, participating extended care facility.

(3) Where an individual has been furnished services in a skilled nursing facility, no payment may be made for such services if he did not require posthospital extended care as specified in §§ 405.126-405.128, irrespective of whether the other requirements of this section were met.

(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) Timely admission to a skilled nursing facility. To be eligible for extended care services an individual must be admitted to a skilled nursing facility within a specified time period. (1) [Reserved]

(2) Skilled nursing facility admissions on or after October 30, 1972. With respect to skilled nursing facility admissions occurring on or after October 30, 1972, or to skilled nursing facility admissions occurring prior to October 30, 1972, with respect to which a final determination (see Subpart G of this part for definition of "final determination") had not been made prior to October 30, 1972, an individual must (i) be admitted to the skilled nursing facility and receive required post-hospital extended care (see 405.126) within 14 days after discharge from a hospital, or (ii) be admitted to the skilled nursing facility within 28 days after such discharge, in the case of an individual who was unable to be admitted to a skilled nursing facility within 14 days because of a shortage of appropriate bed space in the geographic area in which he resides provided he required posthospital extended care (see § 405.126) within 14 days of the hospital discharge and

continued to require such care through the time of his admission to the facility, or (iii) must be admitted to the skilled nursing facility within such time as it would be medically appropriate to begin an active course of treatment in such a facility, in the case of an individual whose condition is such that posthospital extended care (see § 405.126) would not be medically appropriate within 14 days after discharge from a hospital (see paragraph (d)(3) of this section for method of counting days).

(3) Counting days. For the purpose of this section, "within 14 days" or "within 28 days" means the period of 14 or 28 consecutive calendar days (including Saturdays, Sundays, legal holidays, and days, all or part of which is declared to be a nonworkday for Federal employees by statute or Executive order) beginning with the calendar day following the day of discharge from the hospital or, where paragraph (b)(2) of this section applies, beginning with the calendar day following the day of discharge from a skilled nursing facility.

(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).

[31 FR 10118, July 27, 1966, as amended at 34 FR 11204, July 3, 1969; 36 FR 10849, June 4, 1971; 40 FR 23289, May 29, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4428, Feb. 2, 1978]

§ 405.122 Posthospital extended care services; services considered for purposes of limitation on days of coverage. For purposes of the limitation on days of coverage (see §§ 405.120(b) and 405.121), extended care services furnished an individual are taken into account only if one or more of the following conditions apply to such services:

(a) Payment is made with respect to such services;

(b) Payment would be made except for failure to comply with the request for payment and certification requirements described in § 405.165; or

(c) Payment cannot be made for such services because of coinsurance requirements described in § 405.124.

[34 FR 11204, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.123 Posthospital extended care 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.

[31 FR 10119, July 27, 1966. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.124 Posthospital extended care services; coinsurance amount.

(a) Spell of illness beginning before 1969. In any case in which an individual is furnished posthospital extended care services for more than 20 days during a spell of illness 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 (or the actual charge when charges are less than $5 a 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 hospital 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)).

[31 FR 10119, July 27, 1966, as amended at 34 FR 11204, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.125 Extended care services; defined.

(a) Items and services included. Subject to the conditions and limitations in the succeeding paragraphs in this section, the term "extended care services" means the following items and services furnished by a qualified skilled nursing facility (except as provided in paragraphs (d), (f), and (g) of this section and paragraphs (a) (3) and (6) of this section) to an inpatient of such facility:

(1) Nursing care provided by or under the supervision of a registered professional nurse;

(2) Bed and board in connection with the furnishing of such nursing care;

(3) Physical, occupational or speech therapy;

(4) Medical social services;

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

(6) Medical services provided by an intern or resident-in-training;

(7) Diagnostic or therapeutic services; and

(8) Such other services necessary to the health of the patient as are generally provided by skilled nursing facilities.

(b) Excluded services. No item or service is included as an extended care service if it would not be included as an inpatient hospital service under § 405.116 if furnished to an inpatient of a hospital.

(c) Bed and board. Posthospital skilled nursing facility bed and board is covered in full in accommodations containing two to four beds and in skilled nursing facilities in which all accommodations are on a ward basis and charges are not related to the number of beds in a room. Private accommodations are covered in full only where their use is medically indicated, ordinarily when the patient's condition requires him to be isolated. Where private accommodations are furnished for the patient's comfort and their use is not medically indicated, only the reasonable cost of accommodations containing two to four beds is payable under this Subpart A. Where accommodations less expensive

than accommodations containing 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 (not to exceed the reasonable cost of such accommodations) 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.

(d) Physical, occupational or speech therapy. Physical, occupational or speech therapy services are considered as extended care services if furnished by the skilled nursing facility or if furnished by others under arrangements with them made by the facility under which the billing for such services is through such extended care facility.

(e) (1) Drugs and biologicals. Drugs and biologicals are included as extended care services only if they:

(i) Represent a cost to the skilled nursing facility in rendering such services;

(ii) Are furnished to an inpatient for use in the skilled nursing facility or, with respect to a limited supply required until the patient can obtain a continuing supply, are deemed medically necessary to permit or facilitate the patient's departure from the skilled nursing facility; and

(iii) Are ordinarily furnished by such skilled nursing facility for the care and treatment of inpatients.

(2) Supplies, appliances, and equipment. Supplies, appliances, and equipment are included as extended care services only;

(i) If ordinarily furnished by such skilled nursing facility for the care and treatment of inpatients; and

(ii) If furnished to an inpatient for use in the skilled nursing facility except in the case of a temporary or disposable item provided to an inpatient for use beyond his stay which is medically necessary to permit or facilitate the patient's departure from the skilled nursing facility and which is required until such time as the patient can obtain a continuing supply, or in cases where it would be unreasonable or impossible from a medical stand