PART 409—HOSPITAL INSURANCE BENEFITS Authority: 42 U.S.C. 1302 and 1395hh. Source: 48 FR 12541, Mar. 25, 1983, unless otherwise noted. Editorial Note: Nomenclature changes to part 409 appear at 62 FR 46037, Aug. 29, 1997. Subpart A—Hospital Insurance Benefits: General Provisions § 409.1 Statutory basis. This part is based on the identified provisions of the following sections of the Social Security Act: (a) Sections 1812 and 1813 establish the scope of benefits of the hospital insurance program under Medicare Part A and set forth deductible and coinsurance requirements. (b) Sections 1814 and 1815 establish conditions for, and limitations on, payment for services furnished by providers. (c) Section 1820 establishes the critical access hospital program. (d) Section 1861 describes the services covered under Medicare Part A, and benefit periods. (e) Section 1862(a) specifies exclusions from coverage. (f) Section 1881 sets forth the rules for individuals who have end-stage renal disease (ESRD), for organ donors, and for dialysis, transplantation, and other services furnished to ESRD patients. [60 FR 50441, Sept. 29, 1995, as amended at 65 FR 62646, Oct. 19, 2000] § 409.2 Scope. Subparts A through G of this part describe the benefits available under Medicare Part A and set forth the limitations on those benefits, including certain amounts of payment for which beneficiaries are responsible. [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985] § 409.3 Definitions. As used in this part, unless the context indicates otherwise— Arrangements Covered Nominal charge provider Participating Qualified hospital (a) Is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled; (b) Is not primarily engaged in providing skilled nursing care and related services for inpatients who require medical or nursing care; (c) Provides 24-hour nursing service in accordance with Sec. 1861(e)(5) of the Act; (d) If it is a U.S. hospital, is licensed, or approved as meeting the standards for licensing, by the State or local licensing agency; and (e) If it is a foreign hospital, is licensed, or approved as meeting the standard for licensing, by the appropriate foreign licensing agency, and for purposes of furnishing nonemergency services to U.S. residents, is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or by a foreign program under standards that CMS finds to be equivalent to those of JCAHO. [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 51 FR 41338, Nov. 14, 1986; 71 FR 48135, Aug. 18, 2006] § 409.5 General description of benefits. Hospital insurance (Part A of Medicare) helps pay for inpatient hospital or inpatient CAH services and posthospital SNF care. It also pays for home health services and hospice care. There are limitations on the number of days of care that Medicare can pay for and there are deductible and coinsurance amounts for which the beneficiary is responsible. For each type of service, certain conditions must be met as specified in the pertinent sections of this subpart and in part 418 of this chapter regarding hospice care. Conditions for payment of emergency inpatient services furnished by a nonparticipating U.S. hospital and for services furnished in a foreign country are set forth in subparts G and H of part 424 of this chapter. [71 FR 48135, Aug. 18, 2006] Subpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services § 409.10 Included services. (a) Subject to the conditions, limitations, and exceptions set forth in this subpart, the term “inpatient hospital or inpatient CAH services” means the following services furnished to an inpatient of a participating hospital or of a participating CAH or, in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital: (1) Bed and board. (2) Nursing services and other related services. (3) Use of hospital or CAH facilities. (4) Medical social services. (5) Drugs, biologicals, supplies, appliances, and equipment. (6) Certain other diagnostic or therapeutic services. (7) Medical or surgical services provided by certain interns or residents-in-training. (8) Transportation services, including transport by ambulance. (b) Inpatient hospital services (1) Posthospital SNF care, as described in § 409.20, furnished by a hospital or a critical access hospital that has a swing-bed approval. (2) Nursing facility services, described in § 440.155 of this chapter, that may be furnished as a Medicaid service under title XIX of the Act in a swing-bed hospital that has an approval to furnish nursing facility services. (3) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis. (4) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (5) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (6) Certified nurse mid-wife services, as defined in section 1861(gg) of the Act. (7) Qualified psychologist services, as defined in section 1861(ii) of the Act. (8) Services of an anesthetist, as defined in § 410.69 [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 58 FR 30666, May 26, 1993; 64 FR 3648, Jan. 25, 1999; 65 FR 18535, Apr. 7, 2000] § 409.11 Bed and board. (a) Semiprivate and ward accommodations. (b) Private accommodations Conditions for payment in full. (i) The patient's condition requires him or her to be isolated; (ii) The hospital or CAH has no semiprivate or ward accommodations; or (iii) The hospital's or CAH's semiprivate and ward accommodations are fully occupied by other patients, were so occupied at the time the patient was admitted to the hospital or CAH, respectively, for treatment of a condition that required immediate inpatient hospital or inpatient CAH care, and have been so occupied during the interval. (2) Period of payment. (3) Conditions for patient's liability. (i) None of the conditions of paragraph (b)(1) of this section is met; and (ii) The private room was requested by the patient or a member of the family, who, at the time of the request, was informed what the hospital's or CAH's charge would be. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.12 Nursing and related services, medical social services; use of hospital or CAH facilities. (a) Except as provided in paragraph (b) of this section, Medicare pays for nursing and related services, use of hospital or CAH facilities, and medical social services as inpatient hospital or inpatient CAH services only if those services are ordinarily furnished by the hospital or CAH, respectively, for the care and treatment of inpatients. (b) Exception. [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 58 FR 30666, 30667, May 26, 1993] § 409.13 Drugs and biologicals. (a) Except as specified in paragraph (b) of this section, Medicare pays for drugs and biologicals as inpatient hospital or inpatient CAH services only if— (1) They represent a cost to the hospital or CAH; (2) They are ordinarily furnished by the hospital or CAH for the care and treatment of inpatients; and (3) They are furnished to an inpatient for use in the hospital or CAH. (b) Exception. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.14 Supplies, appliances, and equipment. (a) Except as specified in paragraph (b) of this section, Medicare pays for supplies, appliances, and equipment as inpatient hospital or inpatient CAH services only if— (1) They are ordinarily furnished by the hospital or CAH to inpatients; and (2) They are furnished to inpatients for use in the hospital or CAH. (b) Exceptions. (1) The item is one that the beneficiary must continue to use after he or she leaves the hospital or CAH, for example, heart valves or a heart pacemaker, or (2) The item is medically necessary to permit or facilitate the beneficiary's departure from the hospital or CAH and is required until the beneficiary can obtain a continuing supply. Tracheostomy or draining tubes are examples. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.15 Services furnished by an intern or a resident-in-training. Medical or surgical services provided by an intern or a resident-in-training are included as “inpatient hospital or inpatient CAH services” if they are provided— (a) By an intern or a resident-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association, or the Bureau of Professional Education of the American Osteopathic Association; (b) By an intern or a 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 (c) By an intern or a resident-in-training in the field of podiatry under a teaching program approved by the Council on Podiatry Education of the American Podiatry Association. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.16 Other diagnostic or therapeutic services. Diagnostic or therapeutic services other than those provided for in §§ 409.12, 409.13, and 409.14 are considered as inpatient hospital or inpatient CAH services if— (a) They are furnished by the hospital or CAH, or by others under arrangements made by the hospital or CAH; (b) Billing for those services is through the hospital or CAH; and (c) The services are of a kind ordinarily furnished to inpatients either by the hospital or CAH or under arrangements made by the hospital or CAH. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.17 Physical therapy, occupational therapy, and speech-language pathology services. (a) General rules. (2) Physical therapy, occupational therapy or speech-language pathology services must be furnished under a plan that meets the requirements of paragraphs (b) through (d) of this section, or plan requirements specific to the payment policy under which the services are rendered, if applicable. (b) Establishment of the plan. (1) A physician. (2) A nurse practitioner, a clinical nurse specialist or a physician assistant. (3) The physical therapist furnishing the physical therapy services. (4) A speech-language pathologist furnishing the speech-language pathology services. (5) An occupational therapist furnishing the occupational therapy services. (c) Content of the plan. (1) Prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual; and (2) Indicates the diagnosis and anticipated goals. (d) Changes in the plan. [72 FR 66397, Nov. 27, 2007, as amended at 73 FR 69932, Nov. 19, 2008; 75 FR 73613, Nov. 29, 2010] § 409.18 Services related to kidney transplantations. (a) Kidney transplants. (b) Services in connection with kidney donations. (1) If the kidney is intended for an individual who has ESRD and is entitled to Medicare benefits or can be expected to become so entitled within a reasonable time; and (2) Regardless of whether the donor is entitled to Medicare. Subpart C—Posthospital SNF Care § 409.20 Coverage of services. (a) Included services. (1) Nursing care provided by or under the supervision of a registered professional nurse. (2) Bed and board in connection with the furnishing of that nursing care. (3) Physical therapy, occupational therapy, and speech-language pathology services. (4) Medical social services. (5) Drugs, biologicals, supplies, appliances, and equipment. (6) Services furnished by a hospital with which the SNF has a transfer agreement in effect under § 483.70(j) of this chapter. (7) Other services that are generally provided by (or under arrangements made by) SNFs. (b) Excluded services Services that are not considered inpatient hospital services. (2) Services not generally provided by (or under arrangements made by) SNFs. (c) Terminology. (1) The terms SNF swing-bed hospital (2) The term facility (3) The term swing-bed hospital (4) The term post-hospital SNF care [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 58 FR 30667, May 26, 1993; 63 FR 26306, May 12, 1998; 64 FR 3648, Jan. 25, 1999; 64 FR 41681, July 30, 1999; 68 FR 46070, Aug. 4, 2003; 68 FR 50854, Aug. 22, 2003; 69 FR 35529, June 25, 2004; 75 FR 73613, Nov. 29, 2010; 82 FR 32258, July 13, 2017] § 409.21 Nursing care. (a) Basic rule. (b) Exception. [63 FR 26306, May 12, 1998] § 409.22 Bed and board. (a) Semiprivate and ward accommodations. (b) Private accommodations Conditions for payment in full. (i) The patient's condition requires him to be isolated; (ii) The SNF has no semiprivate or ward accommodations; or (iii) The SNF semiprivate and ward accommodations are fully occupied by other patients, were so occupied at the time the patient was admitted to the SNF for treatment of a condition that required immediate inpatient SNF care, and have been so occupied during the interval. (2) Period of payment. (3) Conditions for patient's liability. (i) None of the conditions of paragraph (b)(1) of this section is met, and (ii) The private room was requested by the patient or a member of the family who, at the time of request was informed what the charge would be. § 409.23 Physical therapy, occupational therapy, and speech-language pathology services. Medicare pays for physical therapy, occupational therapy, or speech-language pathology services as posthospital SNF care if they are furnished— (a) By (or under arrangements made by) the facility and billed by (or through) the facility; (b) By qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, or speech-language pathologists as defined in part 484 of this chapter; and (c) In accordance with a plan that meets the requirements of § 409.17(b) through (d) of this part. [75 FR 73613, Nov. 29, 2010] § 409.24 Medical social services. Medicare pays for medical social services as posthospital SNF care, including— (a) Assessment of the social and emotional factors related to the beneficiary's illness, need for care, response to treatment, and adjustment to care in the facility; (b) Case work services to assist in resolving social or emotional problems that may have an adverse effect on the beneficiary's ability to respond to treatment; and (c) Assessment of the relationship of the beneficiary's medical and nursing requirements to his or her home situation, financial resources, and the community resources available upon discharge from facility care. [63 FR 26306, May 12, 1998] § 409.25 Drugs, biologicals, supplies, appliances, and equipment. (a) Drugs and biologicals. (1) They represent a cost to the facility; (2) They are ordinarily furnished by the facility for the care and treatment of inpatients; and (3) They are furnished to an inpatient for use in the facility. (b) Exception. (c) Supplies, appliances, and equipment. (1) Ordinarily furnished by the facility to inpatients; and (2) Furnished to inpatients for use in the facility. (d) Exception. (1) The item is one that the beneficiary must continue to use after leaving, such as a leg brace; or (2) The item is necessary to permit or facilitate the beneficiary's departure from the facility and is required until he or she can obtain a continuing supply, for example, sterile dressings. [63 FR 26307, May 12, 1998] § 409.26 Transfer agreement hospital services. (a) Services furnished by an intern or a resident-in-training. (1) A participating hospital with which the SNF has in effect an agreement under § 483.70(j) of this chapter for the transfer of patients and exchange of medical records; or (2) A hospital that has a swing-bed approval, and is furnishing services to an SNF-level inpatient of that hospital. (b) Other diagnostic or therapeutic services. (1) By a participating hospital with which the SNF has in effect a transfer agreement as described in paragraph (a)(1) of this section; or (2) By a hospital or a CAH that has a swing-bed approval, to its own SNF-level inpatient. [63 FR 26307, May 12, 1998; 82 FR 32258, July 13, 2017] § 409.27 Other services generally provided by (or under arrangements made by) SNFs. In addition to those services specified in §§ 409.21 through 409.26, Medicare pays as posthospital SNF care for such other diagnostic and therapeutic services as are generally provided by (or under arrangements made by) SNFs, including— (a) Medical and other health services as described in subpart B of part 410 of this chapter, subject to any applicable limitations or exclusions contained in that subpart or in § 409.20(b); (b) Respiratory therapy services prescribed by a physician for the assessment, diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function; and (c) Transportation by ambulance that meets the general medical necessity requirements set forth in § 410.40(e)(1) of this chapter. [63 FR 26307, May 12, 1998, as amended at 64 FR 41681, July 30, 1999; 84 FR 63187, Nov. 15, 2019] Subpart D—Requirements for Coverage of Posthospital SNF Care § 409.30 Basic requirements. Posthospital SNF care, including SNF-type care furnished in a hospital or CAH that has a swing-bed approval, is covered only if the beneficiary meets the requirements of this section and only for days when he or she needs and receives care of the level described in § 409.31. A beneficiary in an SNF is also considered to meet the level of care requirements of § 409.31 up to and including the assessment reference date for the initial Medicare assessment prescribed in § 413.343(b) of this chapter, when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. For the purposes of this section, the assessment reference date is defined in accordance with § 483.315(d) of this chapter, and must be set for no later than the eighth day of posthospital SNF care. (a) Pre-admission requirements. (1) Have been hospitalized in a participating or qualified hospital or participating CAH, for medically necessary inpatient hospital or inpatient CAH care, for at least 3 consecutive calendar days, not counting the date of discharge; and (2) Have been discharged from the hospital or CAH in or after the month he or she attained age 65, or in a month for which he or she was entitled to hospital insurance benefits on the basis of disability or end-stage renal disease, in accordance with part 406 of this chapter. (b) Date of admission requirements. 1 1 (2) The following exceptions apply— (i) A beneficiary for whom posthospital SNF care would not be medically appropriate within 30 days after discharge from the hospital or CAH, or a beneficiary enrolled in a Medicare + Choice (M + C) plan, may be admitted at the time it would be medically appropriate to begin an active course of treatment. (ii) If, upon admission to the SNF, the beneficiary was enrolled in an M + C plan, as defined in § 422.4 of this chapter, offering the benefits described in § 422.101(c) of this chapter, the beneficiary will be considered to have met the requirements described in paragraphs (a) and (b) of this section, and also in § 409.31(b)(2), for the duration of the SNF stay. [48 FR 12541, Mar. 25, 1983, as amended at 51 FR 41338, Nov. 14, 1986; 58 FR 30666, 30667, May 26, 1993; 62 FR 46025, Aug. 29, 1997; 63 FR 26307, May 12, 1998; 64 FR 41681, July 30, 1999; 68 FR 50584, Aug. 22, 2003; 72 FR 43436, Aug. 3, 2007; 82 FR 36633, Aug. 4, 2017; 84 FR 38832, Aug. 7, 2019] § 409.31 Level of care requirement. (a) Definition. skilled nursing and skilled rehabilitation services (1) Are ordered by a physician; (2) Require the skills of technical or professional personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists; and (3) Are furnished directly by, or under the supervision of, such personnel. (b) Specific conditions for meeting level of care requirements. (2) Those services must be furnished for a condition— (i) For which the beneficiary received inpatient hospital or inpatient CAH services; or (ii) Which arose while the beneficiary was receiving care in a SNF or swing-bed hospital for a condition for which he or she received inpatient hospital or inpatient CAH services; or (iii) For which, for an M + C enrollee described in § 409.20(c)(4), a physician has determined that a direct admission to a SNF without an inpatient hospital or inpatient CAH stay would be medically appropriate. (3) The daily skilled services must be ones that, as a practical matter, can only be provided in a SNF, on an inpatient basis. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993; 68 FR 50854, Aug. 22, 2003; 70 FR 45055, Aug. 4, 2005] § 409.32 Criteria for skilled services and the need for skilled services. (a) To be considered a skilled service, the service must be so inherently complex that it can be safely and effectively performed only by, or under the supervision of, professional or technical personnel. (b) A condition that does not ordinarily require skilled services may require them because of special medical complications. Under those circumstances, a service that is usually nonskilled (such as those listed in § 409.33(d)) may be considered skilled because it must be performed or supervised by skilled nursing or rehabilitation personnel. For example, a plaster cast on a leg does not usually require skilled care. However, if the patient has a preexisting acute skin condition or needs traction, skilled personnel may be needed to adjust traction or watch for complications. In situations of this type, the complications, and the skilled services they require, must be documented by physicians' orders and nursing or therapy notes. (c) The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. For example, a terminal cancer patient may need some of the skilled services described in § 409.33. [48 FR 12541, Mar. 25, 1983, as amended at 59 FR 65493, Dec. 20, 1994] § 409.33 Examples of skilled nursing and rehabilitation services. (a) Services that could qualify as either skilled nursing or skilled rehabilitation services Overall management and evaluation of care plan. constitute skilled services. (ii) Example. (2) Observation and assessment of the patient's changing condition When observation and assessment constitute skilled services. (ii) Examples. (3) Patient education services When patient education services constitute skilled services. (ii) Examples. (b) Services that qualify as skilled nursing services. (2) Enteral feeding that comprises at least 26 per cent of daily calorie requirements and provides at least 501 milliliters of fluid per day. (3) Nasopharyngeal and tracheostomy aspiration; (4) Insertion and sterile irrigation and replacement of suprapubic catheters; (5) Application of dressings involving prescription medications and aseptic techniques; (6) Treatment of extensive decubitus ulcers or other widespread skin disorder; (7) Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress; (8) Initial phases of a regimen involving administration of medical gases; (9) Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs. (c) Services which would qualify as skilled rehabilitation services. (2) Therapeutic exercises or activities: Therapeutic exercises or activities which, because of the type of exercises employed or the condition of the patient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the patient and the effectiveness of the treatment; (3) Gait evaluation and training: Gait evaluation and training furnished to restore function in a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality; (4) Range of motion exercises: Range of motion exercises which are part of the active treatment of a specific disease state which has resulted in a loss of, or restriction of, mobility (as evidenced by a therapist's notes showing the degree of motion lost and the degree to be restored); (5) Maintenance therapy; Maintenance therapy, when the specialized knowledge and judgment of a qualified therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the patient's needs, and consistent with the patient's capacity and tolerance. For example, a patient with Parkinson's disease who has not been under a rehabilitation regimen may require the services of a qualified therapist to determine what type of exercises will contribute the most to the maintenance of his present level of functioning. (6) Ultrasound, short-wave, and microwave therapy treatment by a qualified physical therapist; (7) Hot pack, hydrocollator, infrared treatments, paraffin baths, and whirlpool; Hot pack hydrocollator, infrared treatments, paraffin baths, and whirlpool in particular cases where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications, and the skills, knowledge, and judgment of a qualified physical therapist are required; and (8) Services of a speech pathologist or audiologist when necessary for the restoration of function in speech or hearing. (d) Personal care services. (1) Administration of routine oral medications, eye drops, and ointments; (2) General maintenance care of colostomy and ileostomy; (3) Routine services to maintain satisfactory functioning of indwelling bladder catheters; (4) Changes of dressings for noninfected postoperative or chronic conditions; (5) Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems; (6) Routine care of the incontinent patient, including use of diapers and protective sheets; (7) General maintenance care in connection with a plaster cast; (8) Routine care in connection with braces and similar devices; (9) Use of heat as a palliative and comfort measure, such as whirlpool and hydrocollator; (10) Routine administration of medical gases after a regimen of therapy has been established; (11) Assistance in dressing, eating, and going to the toilet; (12) Periodic turning and positioning in bed; and (13) General supervision of exercises which have been taught to the patient; including the actual carrying out of maintenance programs, i.e., the performance of the repetitive exercises required to maintain function do not require the skills of a therapist and would not constitute skilled rehabilitation services (see paragraph (c) of this section). Similarly, repetitious exercises to improve gait, maintain strength, or endurance; passive exercises to maintain range of motion in paralyzed extremities, which are not related to a specific loss of function; and assistive walking do not constitute skilled rehabilitation services. [48 FR 12541, Mar. 25, 1983, as amended at 63 FR 26307, May 12, 1998; 64 FR 41681, July 30, 1999] § 409.34 Criteria for “daily basis”. (a) To meet the daily basis requirement specified in § 409.31(b)(1), the following frequency is required: (1) Skilled nursing services or skilled rehabilitation services must be needed and provided 7 days a week; or (2) As an exception, if skilled rehabilitation services are not available 7 days a week those services must be needed and provided at least 5 days a week. (b) A break of one or two days in the furnishing of rehabilitation services will not preclude coverage if discharge would not be practical for the one or two days during which, for instance, the physician has suspended the therapy sessions because the patient exhibited extreme fatigue. § 409.35 Criteria for “practical matter”. (a) General considerations. (b) Examples of circumstances that meet practical matter criteria Beneficiary's condition. (2) Economy and efficiency. [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 85 FR 47632, Aug. 5, 2020] § 409.36 Effect of discharge from posthospital SNF care. If a beneficiary is discharged from a facility after receiving posthospital SNF care, he or she is not entitled to additional services of this kind in the same benefit period unless— (a) He or she is readmitted to the same or another facility within 30 calendar days following the day of discharge (or, before December 5, 1980, within 14 calendar days after discharge); or (b) He or she is again hospitalized for at least 3 consecutive calendar days. Subpart E—Home Health Services Under Hospital Insurance § 409.40 Basis, purpose, and scope. This subpart implements sections 1814(a)(2)(C), 1835(a)(2)(A), and 1861(m) of the Act with respect to the requirements that must be met for Medicare payment to be made for home health services furnished to eligible beneficiaries. [59 FR 65493, Dec. 20, 1994] § 409.41 Requirement for payment. In order for home health services to qualify for payment under the Medicare program the following requirements must be met: (a) The services must be furnished to an eligible beneficiary by, or under arrangements with, an HHA that— (1) Meets the conditions of participation for HHAs at part 484 of this chapter; and (2) Has in effect a Medicare provider agreement as described in part 489, subparts A, B, C, D, and E of this chapter. (b) The certification and recertification requirements for home health services described in § 424.22. (c) All requirements contained in §§ 409.42 through 409.47. [59 FR 65494, Dec. 20, 1994, as amended at 85 FR 27619, May 8, 2020] § 409.42 Beneficiary qualifications for coverage of services. To qualify for Medicare coverage of home health services, a beneficiary must meet each of the following requirements: (a) Confined to the home. (b) Under the care of a physician or allowed practitioner, as defined at § 484.2 of this chapter. (c) In need of skilled services. (1) Intermittent skilled nursing services that meet the criteria for skilled services and the need for skilled services found in § 409.32. (Also see § 409.33(a) and (b) for a description of examples of skilled nursing and rehabilitation services.) These criteria are subject to the following limitations in the home health setting: (i) In the home health setting, management and evaluation of a patient care plan is considered a reasonable and necessary skilled service when underlying conditions or complications are such that only a registered nurse can ensure that essential non-skilled care is achieving its purpose. To be considered a skilled service, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of licensed nurses to promote the patient's recovery and medical safety in view of the overall condition. Where nursing visits are not needed to observe and assess the effects of the non-skilled services being provided to treat the illness or injury, skilled nursing care would not be considered reasonable and necessary, and the management and evaluation of the care plan would not be considered a skilled service. In some cases, the condition of the patient may cause a service that would originally be considered unskilled to be considered a skilled nursing service. This would occur when the patient's underlying condition or complication requires that only a registered nurse can ensure that essential non-skilled care is achieving its purpose. The registered nurse is ensuring that service is safely and effectively performed. However, a service is not considered a skilled nursing service merely because it is performed by or under the supervision of a licensed nurse. Where a service can be safely and effectively performed (or self administered) by non-licensed staff without the direct supervision of a nurse, the service cannot be regarded as a skilled service even if a nurse actually provides the service. (ii) In the home health setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case, and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury. (2) Physical therapy services that meet the requirements of § 409.44(c). (3) Speech-language pathology services that meet the requirements of § 409.44(c). (4) Occupational therapy services in the current and subsequent certification periods (subsequent adjacent episodes) that meet the requirements of § 409.44(c) initially qualify for home health coverage as a dependent service as defined in § 409.45(d) if the beneficiary's eligibility for home health services has been established by virtue of a prior need for intermittent skilled nursing care, speech-language pathology services, or physical therapy in the current or prior certification period. Subsequent to an initial covered occupational therapy service, continuing occupational therapy services which meet the requirements of § 409.44(c) are considered to be qualifying services. (d) Under a plan of care. (e) By whom the services must be furnished. [59 FR 65494, Dec. 20, 1994; 60 FR 39122, Aug. 1, 1995, as amended at 74 FR 58133, Nov. 10, 2009; 76 FR 68606, Nov. 4, 2011; 85 FR 27619, May 8, 2020] § 409.43 Plan of care requirements. (a) Contents. (1) The HHA must be acting upon a plan of care that meets the requirements of this section for HHA services to be covered. (2) For HHA services to be covered, the individualized plan of care must specify the services necessary to meet the patient-specific needs identified in the comprehensive assessment. (3)(i) The plan of care must include all of the following: (A) The identification of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in § 484.60(a) of this chapter that establish the need for such services. (B) Any provision of remote patient monitoring or other services furnished via telecommunications technology (as defined in § 409.46(e)) or audio-only technology. Such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment. (ii) All care provided must be in accordance with the plan of care. (b) Physician's or allowed practitioner's orders. (c) Physician or allowed practitioner signature Request for Anticipated payment signature requirements. (i) A physician or allowed practitioner's orders that— (A) Is recorded in the plan of care; (B) Includes a description of the patient's condition and the services to be provided by the home health agency; (C) Includes an attestation (relating to the physician's or allowed practitioner's orders and the date received) signed and dated by the registered nurse or qualified therapist (as defined in 42 CFR 484.115) responsible for furnishing or supervising the ordered service in the plan of care; and (D) Is copied into the plan of care and the plan of care is immediately submitted to the physician or allowed practitioner; or (ii) A referral prescribing detailed orders for the services to be rendered that is signed and dated by a physician. (2) Final percentage payment signature requirements. (i) By a physician or allowed practitioner as described who meets the certification and recertification requirements of § 424.22 of this chapter; and (ii) Before the claim for each episode (for episodes beginning on or before December 31, 2019) or 30-day period (for periods beginning on or after January 1, 2020) is submitted. (3) Changes to the plan of care signature requirements. (d) Oral (verbal) orders. (e) Frequency of review. (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge with goals met and/or no expectation of a return to home health care and the patient returns to home health care within 60 days. (2) Each review of a beneficiary's plan of care must contain the signature of the physician or allowed practitioner who reviewed it and the date of review. (f) Termination of the plan of care. [59 FR 65494, Dec. 20, 1994, as amended at 65 FR 41210, July 3, 2000; 74 FR 58133, Nov. 10, 2009; 80 FR 68717, Nov. 5, 2015; 82 FR 4578, Jan. 13, 2017; 83 FR 56627, Nov. 13, 2018; 84 FR 60642, Nov. 8, 2019; 85 FR 19285, Apr. 6, 2020; 85 FR 27619, May 8, 2020; 85 FR 70354, Nov. 4, 2020; 86 FR 62418, Nov. 9, 2021] § 409.44 Skilled services requirements. (a) General. (b) Skilled nursing care. (i) In determining whether a service requires the skill of a licensed nurse, consideration must be given to the inherent complexity of the service, the condition of the beneficiary, and accepted standards of medical and nursing practice. (ii) If the nature of a service is such that it can safely and effectively be performed by the average nonmedical person without direct supervision of a licensed nurse, the service cannot be regarded as a skilled nursing service. (iii) The fact that a skilled nursing service can be or is taught to the beneficiary or to the beneficiary's family or friends does not negate the skilled aspect of the service when performed by the nurse. (iv) If the service could be performed by the average nonmedical person, the absence of a competent person to perform it does not cause it to be a skilled nursing service. (2) The skilled nursing care must be provided on a part-time or intermittent basis. (3) The skilled nursing services must be reasonable and necessary for the treatment of the illness or injury. (i) To be considered reasonable and necessary, the services must be consistent with the nature and severity of the beneficiary's illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practice. (ii) The skilled nursing care provided to the beneficiary must be reasonable within the context of the beneficiary's condition. (iii) The determination of whether skilled nursing care is reasonable and necessary must be based solely upon the beneficiary's unique condition and individual needs, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last a long time. (c) Physical therapy, speech-language pathology services, and occupational therapy. (1) Speech-language pathology services and physical or occupational therapy services must relate directly and specifically to a treatment regimen (established by the physician or allowed practitioner) after any needed consultation with the qualified therapist, that is designed to treat the beneficiary's illness or injury. Services related to activities for the general physical welfare of beneficiaries (for example, exercises to promote overall fitness) do not constitute physical therapy, occupational therapy, or speech-language pathology services for Medicare purposes. To be covered by Medicare, all of the requirements apply as follows: (i) The patient's plan of care must describe a course of therapy treatment and therapy goals which are consistent with the evaluation of the patient's function, and both must be included in the clinical record. The therapy goals must be established by a qualified therapist in conjunction with the physician or allowed practitioner. (ii) The patient's clinical record must include documentation describing how the course of therapy treatment for the patient's illness or injury is in accordance with accepted professional standards of clinical practice. (iii) Therapy treatment goals described in the plan of care must be measurable, and must pertain directly to the patient's illness or injury, and the patient's resultant impairments. (iv) The patient's clinical record must demonstrate that the method used to assess a patient's function included objective measurements of function in accordance with accepted professional standards of clinical practice enabling comparison of successive measurements to determine the effectiveness of therapy goals. Such objective measurements would be made by the qualified therapist using measurements which assess activities of daily living that may include but are not limited to eating, swallowing, bathing, dressing, toileting, walking, climbing stairs, or using assistive devices, and mental and cognitive factors. (2) Physical and occupational therapy and speech-language pathology services must be reasonable and necessary. To be considered reasonable and necessary, the following conditions must be met: (i) The services must be considered under accepted standards of professional clinical practice, to be a specific, safe, and effective treatment for the beneficiary's condition. Each of the following requirements must also be met: (A) The patient's function must be initially assessed and periodically reassessed by a qualified therapist, of the corresponding discipline for the type of therapy being provided, using a method which would include objective measurement as described in § 409.44(c)(1)(iv). If more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must perform the assessment and periodic reassessments. The measurement results and corresponding effectiveness of the therapy, or lack thereof, must be documented in the clinical record. (B) At least every 30 calendar days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient in accordance with § 409.44(c)(2)(i)(A). Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionally reassess the patient in accordance with § 409.44(c)(2)(i)(A) at least every 30 calendar days. (C) As specified in paragraphs (c)(2)(i)(A) and (B) of this section, therapy visits for the therapy discipline(s) not in compliance with these policies will not be covered until the following conditions are met: ( 1 2 3 ( 2 ( 3 (D) If the criteria for maintenance therapy, described at § 409.44(c)(2)(iii)(B) and (C) of this section are not met, the following criteria must also be met for subsequent therapy visits to be covered: ( 1 ( 2 1 (E) Clinical notes written by therapy assistants may supplement the clinical record, and if included, must include the date written, the signature, professional designation, and objective measurements or description of changes in status (if any) relative to each goal being addressed by treatment. Assistants may not make clinical judgments about why progress was or was not made, but must report the progress or the effectiveness of the therapy (or lack thereof) objectively. (F) Documentation by a qualified therapist must include the following: ( 1 ( 2 ( 3 ( 4 (ii) The services must be of such a level of complexity and sophistication or the condition of the beneficiary must be such that the services required can safely and effectively be performed only by a qualified physical therapist or by a qualified physical therapy assistant under the supervision of a qualified physical therapist, by a qualified speech-language pathologist, or by a qualified occupational therapist or a qualified occupational therapy assistant under the supervision of a qualified occupational therapist (as defined in § 484.115 of this chapter). Services that do not require the performance or supervision of a physical therapist or an occupational therapist are not considered reasonable or necessary physical therapy or occupational therapy services, even if they are performed by or supervised by a physical therapist or occupational therapist. Services that do not require the skills of a speech-language pathologist are not considered to be reasonable and necessary speech-language pathology services even if they are performed by or supervised by a speech-language pathologist. (iii) For therapy services to be covered in the home health setting, one of the following three criteria must be met: (A) There must be an expectation that the beneficiary's condition will improve materially in a reasonable (and generally predictable) period of time based on the physician's or allowed practitioner's assessment of the beneficiary's restoration potential and unique medical condition. ( 1 ( 2 ( 3 (B) The unique clinical condition of a patient may require the specialized skills, knowledge, and judgment of a qualified therapist to design or establish a safe and effective maintenance program required in connection with the patient's specific illness or injury. ( 1 ( 2 (C) The unique clinical condition of a patient may require the specialized skills of a qualified therapist or therapist assistant to perform a safe and effective maintenance program required in connection with the patient's specific illness or injury. Where the clinical condition of the patient is such that the complexity of the therapy services required— ( 1 ( 2 (iv) The amount, frequency, and duration of the services must be reasonable and necessary, as determined by a qualified therapist and/or physician or allowed practitioner, using accepted standards of clinical practice. (A) Where factors exist that would influence the amount, frequency or duration of therapy services, such as factors that may result in providing more services than are typical for the patient's condition, those factors must be documented in the plan of care and/or functional assessment. (B) Clinical records must include documentation using objective measures that the patient continues to progress towards goals. If progress cannot be measured, and continued progress towards goals cannot be expected, therapy services cease to be covered except when— ( 1 ( 2 [59 FR 65494, Dec. 20, 1994, as amended at 74 FR 58133, Nov. 10, 2009; 75 FR 70461, Nov. 17, 2010; 76 FR 68606, Nov. 4, 2011; 77 FR 67162, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014; 82 FR 4578, Jan. 13, 2017; 84 FR 60642, Nov. 8, 2019; 85 FR 27619, May 8, 2020] § 409.45 Dependent services requirements. (a) General. (b) Home health aide services. (1) The reason for the visits by the home health aide must be to provide hands-on personal care to the beneficiary or services that are needed to maintain the beneficiary's health or to facilitate treatment of the beneficiary's illness or injury. The physician or allowed practitioner's orders must indicate the frequency of the home health aide services required by the beneficiary. These services may include but are not limited to: (i) Personal care services such as bathing, dressing, grooming, caring for hair, nail and oral hygiene that are needed to facilitate treatment or to prevent deterioration of the beneficiary's health, changing the bed linens of an incontinent beneficiary, shaving, deodorant application, skin care with lotions and/or powder, foot care, ear care, feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the beneficiary's condition, routine catheter care, and routine colostomy care), assistance with ambulation, changing position in bed, and assistance with transfers. (ii) Simple dressing changes that do not require the skills of a licensed nurse. (iii) Assistance with medications that are ordinarily self-administered and that do not require the skills of a licensed nurse to be provided safely and effectively. (iv) Assistance with activities that are directly supportive of skilled therapy services but do not require the skills of a therapist to be safely and effectively performed, such as routine maintenance exercises and repetitive practice of functional communication skills to support speech-language pathology services. (v) Routine care of prosthetic and orthotic devices. (2) The services to be provided by the home health aide must be— (i) Ordered by a physician or allowed practitioner in the plan of care; and (ii) Provided by the home health aide on a part-time or intermittent basis. (3) The services provided by the home health aide must be reasonable and necessary. To be considered reasonable and necessary, the services must— (i) Meet the requirement for home health aide services in paragraph (b)(1) of this section; (ii) Be of a type the beneficiary cannot perform for himself or herself; and (iii) Be of a type that there is no able or willing caregiver to provide, or, if there is a potential caregiver, the beneficiary is unwilling to use the services of that individual. (4) The home health aide also may perform services incidental to a visit that was for the provision of care as described in paragraphs (b)(3)(i) through (iii) of this section. For example, these incidental services may include changing bed linens, personal laundry, or preparing a light meal. (c) Medical social services. (1) The services are ordered by a physician or allowed practitioner and included in the plan of care. (2)(i) The services are necessary to resolve social or emotional problems that are expected to be an impediment to the effective treatment of the beneficiary's medical condition or to his or her rate of recovery. (ii) If these services are furnished to a beneficiary's family member or caregiver, they are furnished on a short-term basis and it can be demonstrated that the service is necessary to resolve a clear and direct impediment to the effective treatment of the beneficiary's medical condition or to his or her rate of recovery. (3) The frequency and nature of the medical social services are reasonable and necessary to the treatment of the beneficiary's condition. (4) The medical social services are furnished by a qualified social worker or qualified social work assistant under the supervision of a social worker as defined in § 484.115 of this chapter. (5) The services needed to resolve the problems that are impeding the beneficiary's recovery require the skills of a social worker or a social work assistant under the supervision of a social worker to be performed safely and effectively. (d) Occupational therapy. (e) Durable medical equipment. (f) Medical supplies. (g) Intern and resident services. Approved (1) Approved by the Accreditation Council for Graduate Medical Education; (2) In the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association; (3) In the case of an intern or resident-in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or (4) In the case of an intern or resident-in-training in the field of podiatry, approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association. [59 FR 65495, Dec. 20, 1994; 60 FR 39122, 39123, Aug. 1, 1995, as amended at 82 FR 4578, Jan. 13, 2017; 85 FR 27620, May 8, 2020] § 409.46 Allowable administrative costs. Services that are allowable as administrative costs but are not separately billable include, but are not limited to, the following: (a) Registered nurse initial evaluation visits. (b) Visits by registered nurses or qualified professionals for the supervision of home health aides. (c) Respiratory care services. (d) Dietary and nutrition personnel. (e) Telecommunications technology. [59 FR 65496, Dec. 20, 1994, as amended at 82 FR 4578, Jan. 13, 2017; 83 FR 56627, Nov. 13, 2018; 85 FR 27620, May 8, 2020; 85 FR 70354, Nov. 4, 2020] § 409.47 Place of service requirements. To be covered, home health services must be furnished in either the beneficiary's home or an outpatient setting as defined in this section. (a) Beneficiary's home. (b) Outpatient setting. (1) Require equipment that cannot be made available at the beneficiary's home; or (2) Are furnished while the beneficiary is at the facility to receive services requiring equipment described in paragraph (b)(1) of this section. [59 FR 65496, Dec. 20, 1994, as amended at 82 FR 4578, Jan. 13, 2017] § 409.48 Visits. (a) Number of allowable visits under Part A. (b) Number of visits under Part B. (c) Definition of visit. (1) Generally, one visit may be covered each time an HHA employee or someone providing home health services under arrangements enters the beneficiary's home and provides a covered service to a beneficiary who meets the criteria of § 409.42 (confined to the home, under the care of a physician or allowed practitioner, in need of skilled services, and under a plan of care). (2) If the HHA furnishes services in an outpatient facility under arrangements with the facility, one visit may be covered for each type of service provided. (3) If two individuals are needed to provide a service, two visits may be covered. If two individuals are present, but only one is needed to provide the care, only one visit may be covered. (4) A visit is initiated with the delivery of covered home health services and ends at the conclusion of delivery of covered home health services. In those circumstances in which all reasonable and necessary home health services cannot be provided in the course of a single visit, HHA staff or others providing services under arrangements with the HHA may remain at the beneficiary's residence between visits (for example, to provide non-covered services). However, if all covered services could be provided in the course of one visit, only one visit may be covered. [59 FR 65497, Dec. 20, 1994, as amended at 85 FR 27620, May 8, 2020] § 409.49 Excluded services. (a) Drugs and biologicals. (1) A drug is any chemical compound that may be used on or administered to humans or animals as an aid in the diagnosis, treatment or prevention of disease or other condition or for the relief of pain or suffering or to control or improve any physiological pathologic condition. (2) A biological is any medicinal preparation made from living organisms and their products including, but not limited to, serums, vaccines, antigens, and antitoxins. (b) Transportation. (c) Services that would not be covered as inpatient services. (d) Housekeeping services. (e) Services covered under the End Stage Renal Disease (ESRD) program. (f) Prosthetic devices. (g) Medical social services provided to family members. (h) Services covered under the home infusion therapy benefit. [59 FR 65497, Dec. 20, 1994; 60 FR 39123, Aug. 1, 1995; 85 FR 70354, Nov. 4, 2020] § 409.50 Coinsurance for durable medical equipment (DME) and applicable disposable devices furnished as a home health service. The coinsurance liability of the beneficiary or other person for the following home health services is: (a) DME—20 percent of the customary (insofar as reasonable) charge. (b) An applicable disposable device (as defined in section 1834(s)(2) of the Act)—20 percent of the payment amount for the disposable Negative Pressure Wound Therapy (NPWT) device (as that term is defined in § 484.202 of this chapter). [81 FR 76796, Nov. 3, 2016, as amended at 88 FR 77874, Nov. 13, 2023] Subpart F—Scope of Hospital Insurance Benefits § 409.60 Benefit periods. (a) When benefit periods begin. (b) When benefit periods end (i) A hospital that meets the requirements of section 1861(e)(1) of the Act. (ii) A CAH that meets the requirements of section 1820 of the Act. (iii) A SNF that meets the requirements of sections 1819(a)(1) or 1861(y) of the Act. (2) For purposes of ending a benefit period, a beneficiary was an inpatient of a SNF if his or her care in the SNF met the skilled level of care requirements specified in § 409.31(b) (1) and (3). (c) Presumptions. (i) A beneficiary's care met the skilled level of care requirements if inpatient SNF claims were paid for those services under Medicare or Medicaid, unless: (A) Such payments were made under § 411.400 or Medicaid administratively necessary days provisions which result in payment for care not meeting the skilled level of care requirements, or (B) A Medicare denial and a Medicaid payment are made for the same period, in which case the presumption in paragraph (c)(2)(ii) of this section applies; (ii) A beneficiary's care met the skilled level of care requirements if a SNF claim was paid under section 1879(e) of the Social Security Act; (iii) A beneficiary's care did not meet the skilled level of care requirements if a SNF claim was paid for the services under § 411.400; (iv) A beneficiary's care did not meet the skilled level of care requirements if a Medicaid SNF claim was denied on the grounds that the services were not at the skilled level of care (even if paid under applicable Medicaid administratively necessary days provisions which result in payment for care not meeting the skilled level of care requirements); (2) For purposes of determining whether a beneficiary was an inpatient of a SNF under paragraph (b)(2) of this section a beneficiary's care in a SNF is presumed— (i) To have met the skilled level of care requirements during any period for which the beneficiary was assigned to one of the Resource Utilization Groups designated as representing the required level of care, as provided in § 409.30. (ii) To have met the skilled level of care requirements if a Medicaid or Medicare claim was denied on grounds other than that the services were not at the skilled level of care; (iii) Not to have met the skilled level of care requirements if a Medicare SNF claim was denied on the grounds that the services were not at the skilled level of care and payment was not made under § 411.400; or (iv) Not to have met the skilled level of care requirements if no Medicare or Medicaid claim was submitted by the SNF. (3) If information upon which to base a presumption is not readily available, the intermediary may, at its discretion review the beneficiary's medical records to determine whether he or she was an inpatient of a SNF as set forth under paragraph (b)(2) of this section. (4) When the intermediary makes a benefit period determination based upon paragraph (c)(1) of this section, the beneficiary may seek to reverse the benefit period determination by timely appealing the prior Medicare SNF claim determination under part 405, subpart G of this chapter, or the prior Medicaid SNF claim under part 431, subpart E of this chapter. (5) When the intermediary makes a benefit period determination under paragraph (c)(2) of this section, the beneficiary will be notified of the basis for the determination, and of his or her right to present evidence to rebut the determination that the skilled level of care requirements specified in § 409.31 (b)(1) and (b)(3) were or were not met on reconsideration and appeal under 42 CFR, part 405, subpart G of this chapter. (d) Limitation on benefit period determinations. (1) Medicare will recognize only the initial level of care characterization for that prior SNF stay (or if appealed under 42 CFR part 405, subpart G of this chapter, the level of care determined under appeal); or (2) If part of a prior SNF stay has one level of care characterization and another part has another level of care characterization, Medicare will recognize only the initial level of care characterization for a particular part of a prior SNF stay (or if appealed under 42 CFR part 405, subpart G of this chapter, the level of care determined under appeal). (e) Relation of benefit period to benefit limitations. [52 FR 22645, June 15, 1987; 52 FR 28824, Aug. 4, 1987, as amended at 58 FR 30667, May 26, 1993; 63 FR 26307, May 12, 1998; 70 FR 45055, Aug. 4, 2005] § 409.61 General limitations on amount of benefits. (a) Inpatient hospital or inpatient CAH services Regular benefit days. (i) For the first 60 days (referred to in this subpart as full benefit days (ii) For the next 30 days (referred to in this subpart as coinsurance days (2) Lifetime reserve days. (3) Order of payment for inpatient hospital or inpatient CAH services. (i) The 60 full benefit days; (ii) The 30 coinsurance days; (iii) The remaining lifetime reserve days. (b) Posthospital SNF care furnished by a SNF, or by a hospital or a CAH with a swing-bed approval. (c) Renewal of inpatient benefits. (d) Home health services. 1 1 (1) For DME furnished by an HHA that is a nominal charge provider, Medicare Part A pays 80 percent of fair compensation. (2) For DME furnished by an HHA that is not a nominal charge provider, Medicare Part A pays the lesser of the following: (i) 80 percent of the reasonable cost of the service. (ii) The reasonable cost of, or the customary charge for, the service, whichever is less, minus 20 percent of the customary (insofar as reasonable) charge for the service. [48 FR 12541, Mar. 25, 1983, as amended at 51 FR 41339, Nov. 14, 1986; 54 FR 4027, Jan. 27, 1989; 58 FR 30666, 30667, May 26, 1993] § 409.62 Lifetime maximum on inpatient psychiatric care. There is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary. Therefore, once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are available to that individual. § 409.63 Reduction of inpatient psychiatric benefit days available in the initial benefit period. (a) Reduction rule. (2) Reduction is required only if the hospital was participating in Medicare as a psychiatric hospital on the individual's first day of entitlement. (3) The reduction applies only to the beneficiary's first benefit period. For subsequent benefit periods, the 90 benefit days, plus any remaining lifetime reserve days, subject to the 190 day lifetime limit on psychiatric hospital care, are available. (b) Application to general hospital days. (2) After entitlement, all psychiatric care days, whether in a general or a psychiatric hospital, are counted toward the number of days available in the initial benefit period. (c) Examples: (2) During the 150-day period preceding Medicare entitlement, an individual had been a patient of a general hospital for 60 days of inpatient psychiatric care and had spent 90 days in a psychiatric hospital, ending with the first day of entitlement. During the initial benefit period, the beneficiary spent 90 days in a general hospital and received psychiatric care there. The 60 days spent in the general hospital for psychiatric treatment before entitlement do not reduce the benefits available in the first benefit period. Only the 90 days spent in the psychiatric hospital before entitlement reduce such benefits, leaving a total of 60 available psychiatric days. However, after entitlement, the reduction applies not only to days spent in a psychiatric hospital, but also to days of psychiatric treatment in a general hospital. Thus, Medicare payment could be made only for 60 of the 90 days spent in the general hospital. (3) An individual was admitted to a general hospital for a mental condition and, after 10 days, transferred to a participating psychiatric hospital. The individual remained in the psychiatric hospital for 78 days before becoming entitled to hospital insurance benefits and for 130 days after entitlement. The beneficiary was then transferred to a general hospital and received treatment of a medical condition for 20 days. The 10 days spent in the general hospital during the 150-day pre-entitlement period have no effect on the inpatient hospital benefit days available to the individual for psychiatric care in the first benefit period, even though the general hospital stay was for a mental condition. Only the 78 days spent in the psychiatric hospital during the pre-entitlement period are subtracted from the 150 benefit days. Accordingly, the individual has 72 days of psychiatric care (150 days less 78 days) available in the first benefit period. Benefits could be paid for the individual's hospitalization during the first benefit period in the following manner. For the 130-day psychiatric hospital stay, 72 days (60 full benefit days and 12 coinsurance days), and for the general hospital stay, 20 days (18 coinsurance and 2 lifetime reserve days). § 409.64 Services that are counted toward allowable amounts. (a) Except as provided in paragraph (b) of this section for lifetime reserve days, all covered inpatient days and home health visits are counted toward the allowable amounts specified in §§ 409.61 through 409.63 if— (1) They are paid for by Medicare; or (2) They would be paid for by Medicare if the following requirements had been met: (i) A proper and timely request for payment had been filed; and (ii) The hospital, CAH, SNF, or home health agency had submitted all necessary evidence, including physician or allowed practitioner certification of need for services when such certification was required; (3) They could not be paid for because the total payment due was equal to, or less than, the applicable deductible and coinsurance amounts. (b) Exception. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30667, May 26, 1993; 85 FR 70354, Nov. 4, 2020] § 409.65 Lifetime reserve days. (a) Election not to use lifetime reserve days. (2) It may be advantageous to elect not to use lifetime reserve days if the beneficiary has private insurance coverage that begins after the first 90 inpatient days in a benefit period, or if the daily charge is only slightly higher than the lifetime reserve days coinsurance amount. In such cases, the beneficiary may want to save the lifetime reserve days for future care that may be more expensive. (3) If the beneficiary elects not to use lifetime reserve days for a particular hospital or CAH stay, they are still available for a later stay. However, once the beneficiary uses lifetime reserve days, they can never be renewed. (4) If the beneficiary elects not to use lifetime reserve days, the hospital or CAH may require him or her to pay for any services furnished after the regular days are exhausted. (b) Deemed election. (c) Who may file an election. (1) The beneficiary; or (2) If the beneficiary is physically or mentally unable to act, by the beneficiary's legal representative. In addition, if some other payment source is available, such as private insurance, any person authorized under § 405.1664 of this chapter to execute a request for payment for the beneficiary may file the election. (d) Filing the election. (2) The election may be filed at the time of admission to the hospital or CAH or at any time thereafter up to 90 days after the beneficiary's discharge. (3) A retroactive election (that is, one made after lifetime reserve days have been used because the regular days were exhausted), is not acceptable unless it is approved by the hospital or CAH. (e) Period covered by election General rule. (2) Exception. (i) If the beneficiary has one or more regular benefit days (see § 409.61(a)(1) of this chapter) remaining in the benefit period upon entering the hospital or CAH, an election not to use lifetime reserve days will apply automatically to all days that are not outlier days. The beneficiary may also elect not to use lifetime reserve days for outlier days but this election must apply to all outlier days. (ii) If the beneficiary has no regular benefit days (see § 409.61(a)(1) of this chapter) remaining in the benefit period upon entering the hospital or CAH, an election not to use lifetime reserve days must apply to the entire hospital or CAH stay. [48 FR 12541, Mar. 25, 1983, as amended at 48 FR 39837, Sept. 1, 1983; 49 FR 323, Jan. 3, 1984; 58 FR 30666, 30667, May 26, 1993] § 409.66 Revocation of election not to use lifetime reserve days. (a) Except as provided in paragraph (c) of this section, a beneficiary (or anyone authorized to execute a request for payment, if the beneficiary is incapacitated) may revoke an election not to use lifetime reserve days during hospitalization or within 90 days after discharge. (b) The revocation must be submitted to the hospital or CAH in writing and identify the stay or stays to which it applies. (c) Exceptions. (1) After the beneficiary dies; or (2) After the hospital or CAH has filed a claim under the supplementary medical insurance program (Medicare Part B), for medical and other health services furnished to the beneficiary on the days in question. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.68 Guarantee of payment for inpatient hospital or inpatient CAH services furnished before notification of exhaustion of benefits. (a) Conditions for payment. (1) The services were furnished before CMS or the intermediary notified the hospital or CAH that the beneficiary had exhausted the available benefit days and was not entitled to have payment made for those services. (2) At the time the hospital or CAH furnished the services, it was unaware that the beneficiary had exhausted the available benefit days and could reasonably have assumed that he or she was entitled to have payment made for these services. (3) Payment would be precluded solely because the beneficiary has no benefit days available for the particular hospital or CAH stay. (4) The hospital or CAH claims reimbursement for the services and refunds any payments made for those services by the beneficiary or by another person on his or her behalf. (b) Limitations on payment. (2) Payment may not be made under this section for any day after the hospital or CAH is notified that the beneficiary has exhausted the available benefit days. (c) Recovery from the beneficiary. [48 FR 12541, Mar. 25, 1983, as amended at 50 FR 33033, Aug. 16, 1985; 58 FR 30666, May 26, 1993] Subpart G—Hospital Insurance Deductibles and Coinsurance § 409.80 Inpatient deductible and coinsurance: General provisions. (a) What they are. (2) The hospital or CAH or SNF may charge these amounts to the beneficiary or someone on his or her behalf. (b) Changes in the inpatient deductible and coinsurance amounts. (2) Since the coinsurance amounts are, by statute, specific fractions of the deductible, they change when the deductible changes. [48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993] § 409.82 Inpatient hospital deductible. (a) General provisions (2) Although the beneficiary may be hospitalized several times during a benefit period, the deductible is charged only once during that period. If the beneficiary begins more than one benefit period in the same year, a deductible is charged for each of those periods. (3) For services furnished before January 1, 1982, the applicable deductible is the one in effect when the benefit period began. (4) For services furnished after December 31, 1981, the applicable deductible is the one in effect during the calendar year in which the services were furnished. (b) Specific deductible amounts. Federal Register (c) Exception to published amounts. [48 FR 12541, Mar. 25, 1983, as amended at 54 FR 4026, Jan. 27, 1989; 58 FR 30666, 30667, May 26, 1993] § 409.83 Inpatient hospital coinsurance. (a) General provisions (2) For each day from the 61st to the 90th day, the coinsurance amount is 1/4 (3) For each day from the 91st to the 150th day (lifetime reserve days), the coinsurance amount is 1/2 (4) For coinsurance days before January 1, 1982, the coinsurance amount is based on the deductible applicable for the calendar year in which the benefit period began. The coinsurance amounts do not change during a beneficiary's benefit period even though the coinsurance days may fall in a subsequent year for which a higher deductible amount has been determined. (5) For coinsurance days after December 31, 1981, the coinsurance amount is based on the deductible applicable for the calendar year in which the services were furnished. For example, if an individual starts a benefit period by being admitted to a hospital in 1981 and remains in the hospital long enough to use coinsurance days in 1982, the coinsurance amount charged for those days is based on the 1982 inpatient hospital deductible. (b) Specific coinsurance amounts. Federal Register (c) Exceptions to published amounts. (2) If the actual charge to the patient for the 91st through the 150th day (lifetime reserve days) is less than the coinsurance amount applicable for the calendar year in which the services were furnished, the beneficiary is deemed to have elected not to use the days because he or she would not benefit from using them. [48 FR 12541, Mar. 25, 1983, as amended at 54 FR 4026, Jan. 27, 1989; 58 FR 30666, 30667, May 26, 1993] § 409.85 Skilled nursing facility (SNF) care coinsurance. (a) General provisions. (2) For each day from the 21st through the 100th day, the coinsurance is 1/8 (3) For coinsurance days before January 1, 1982, the coinsurance amount is based on the deductible applicable for the year in which the benefit period began. The coinsurance amounts do not change during a beneficiary's benefit period even though the coinsurance days may fall in a subsequent year for which a higher deductible amount has been determined. (4) For coinsurance days after December 31, 1981, the coinsurance amount is based on the deductible applicable for the calendar year in which the services were furnished. (b) Specific coinsurance amounts. Federal Register (c) Exception to published amounts. [48 FR 12541, Mar. 25, 1983, as amended at 54 FR 4026, Jan. 27, 1989] § 409.87 Blood deductible. (a) General provisions. (2) A unit of packed red cells is treated as the equivalent of a unit of whole blood. (3) Medicare does not pay for the first 3 units of whole blood or units of packed red cells that a beneficiary receives, during a calendar year, as an inpatient of a hospital or CAH or SNF, or on an outpatient basis under Medicare Part B. (4) The deductible does not apply to other blood components such as platelets, fibrinogen, plasma, gamma globulin, and serum albumin, or to the cost of processing, storing, and administering blood. (5) The blood deductible is in addition to the inpatient hospital deductible and daily coinsurance. (6) The Part A blood deductible is reduced to the extent that the Part B blood deductible has been applied. For example, if a beneficiary had received one unit under Medicare Part B, and later in the same benefit period received three units under Medicare Part A, Medicare Part A would pay for the third of the latter units. (As specified in § 410.161 of this chapter, the Part B blood deductible is reduced to the extent a blood deductible has been applied under Medicare Part A.) (b) Beneficiary's responsibility for the first 3 units of whole blood or packed red cells Basic rule. (2) Exception. (c) Provider's right to charge for the first 3 units of whole blood or packed red cells Basic rule. (2) Exception. (i) The blood or packed red cells has been replaced. (ii) The provider (or its blood supplier) receives, from an individual or a blood bank, a replacement offer that meets the criteria specified in paragraph (d) of this section. The provider is precluded from charging even if it or its blood supplier rejects the replacement offer. (iii) The provider obtained the blood or packed red cells at no charge other than a processing or service charge and it is therefore deemed to have been replaced. (d) Criteria for replacement of blood. (1) The replacement blood would not endanger the health of a beneficiary; and (2) The prospective donor's health would not be endangered by making a blood donation. [48 FR 12541, Mar. 25, 1983, as amended at 56 FR 8840, Mar. 1, 1991; 57 FR 36014, Aug. 12, 1992; 58 FR 30666, 30667, May 26, 1993] § 409.89 Exemption of kidney donors from deductible and coinsurance requirements. The deductible and coinsurance requirements set forth in this subpart do not apply to any services furnished to an individual in connection with the donation of a kidney for transplant surgery. Subpart H—Payment of Hospital Insurance Benefits Source: 53 FR 6633, Mar. 2, 1988, unless otherwise noted. § 409.100 To whom payment is made. (a) Basic rule. (1) Medicare pays hospital insurance benefits only to a participating provider. (2) For home health services (including medical supplies described in section 1861(m)(5) of the Act, but excluding durable medical equipment to the extent provided for in such section) furnished to an individual who at the time the item or service is furnished is under a plan of care of an HHA, payment is made to the HHA (without regard to whether the item or service is furnished by the HHA directly, under arrangement with the HHA, or under any other contracting or consulting arrangement). (b) Exceptions. (1) For emergency services furnished by a nonparticipating hospital, to the hospital or to the beneficiary, under the conditions prescribed in subpart G of part 424 of this chapter. (2) For services furnished by a Canadian or Mexican hospital, to the hospital or to the beneficiary, under the conditions prescribed in subpart H of part 424 of this chapter. [53 FR 6633, Mar. 2, 1988, as amended at 65 FR 41211, July 3, 2000] § 409.102 Amounts of payment. (a) The amounts Medicare pays for hospital insurance benefits are generally determined in accordance with part 412 or part 413 of this chapter. (b) Except as provided in §§ 409.61(d) and 409.89, hospital insurance benefits are subject to the deductible and coinsurance requirements set forth in subpart G of this part.