Hospital Insurance Benefits

Statutory basis.

This provision identifies the sections of the Social Security Act that serve as the statutory foundation for Medicare Part A hospital insurance benefits.

Included services.

This provision defines the scope of inpatient hospital services covered under Medicare Part A, including specific inclusions and exclusions.

To whom payment is made.

This provision specifies the entities to whom Medicare hospital insurance benefits are paid, including participating providers and exceptions for emergency or foreign services.

Amounts of payment.

This provision outlines the general methodology for determining Medicare payment amounts for hospital insurance benefits, including references to deductible and coinsurance requirements.

Bed and board.

Medicare Part A covers semiprivate or ward accommodations, and private rooms under specific medical necessity or availability conditions, with provisions for patient liability for private room charges.

Nursing and related services, medical social services; use of hospital or CAH facilities.

Medicare covers nursing, medical social services, and facility use when ordinarily furnished for inpatient care, but excludes private duty nursing services.

Drugs and biologicals.

Medicare covers drugs and biologicals furnished to inpatients that represent a hospital cost, with limited exceptions for medically necessary discharge supplies.

Supplies, appliances, and equipment.

Medicare covers supplies, appliances, and equipment furnished to inpatients, including specific items required for use after discharge.

Services furnished by an intern or a resident-in-training.

Medical or surgical services provided by interns or residents are covered as inpatient services if performed under an approved teaching program.

Other diagnostic or therapeutic services.

Diagnostic or therapeutic services are covered as inpatient services if furnished by the hospital or under arrangements, and billed through the hospital.

Physical therapy, occupational therapy, and speech-language pathology services.

Therapy services must be furnished by qualified professionals under a physician-approved plan of care that specifies type, frequency, and duration.

Services related to kidney transplantations.

Medicare covers kidney transplantation surgery in approved centers and services related to kidney donations, regardless of donor Medicare eligibility.

Scope.

This section outlines the Medicare Part A benefits and limitations described in the subparts of this part.

Coverage of services.

This section defines post-hospital skilled nursing facility (SNF) care services and exclusions, including the relationship between hospital and SNF services.

Nursing care.

Medicare covers nursing care as posthospital skilled nursing facility services when provided by or under the supervision of a registered professional nurse.

Bed and board.

Medicare covers semiprivate or ward accommodations in full, with specific conditions and limitations for private room coverage and patient liability.

Physical therapy, occupational therapy, and speech-language pathology services.

Medicare covers therapy services in a skilled nursing facility when furnished by qualified professionals under a physician-approved plan.

Medical social services.

Medicare covers medical social services in a skilled nursing facility, including assessments of social and emotional factors related to a beneficiary's illness and discharge planning.

Drugs, biologicals, supplies, appliances, and equipment.

Medicare covers drugs, biologicals, and medical supplies furnished to inpatients in a skilled nursing facility, with limited exceptions for post-discharge use.

Transfer agreement hospital services.

Medicare covers diagnostic or therapeutic services and services by interns or residents when provided through a formal transfer agreement between a skilled nursing facility and a hospital.

Other services generally provided by (or under arrangements made by) SNFs.

Medicare covers additional diagnostic and therapeutic services, including respiratory therapy and ambulance transportation, when provided by or under arrangements with a skilled nursing facility.

Definitions.

As used in this part, unless the context indicates otherwise—

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 ca...

Level of care requirement.

Medicare coverage for skilled nursing or rehabilitation services requires that services be ordered by a physician, require professional skills, and be provided on a daily basis.

Criteria for skilled services and the need for skilled services.

Skilled services must be inherently complex and require professional personnel, though special medical complications may necessitate skilled care for otherwise nonskilled services.

Examples of skilled nursing and rehabilitation services.

This provision defines the criteria and provides examples for services that qualify as skilled nursing or skilled rehabilitation, distinguishing them from personal care services.

Criteria for “daily basis”.

This provision establishes the frequency requirements for skilled nursing or rehabilitation services to meet the daily basis coverage criteria.

Criteria for “practical matter”.

This provision outlines the factors to consider when determining if inpatient care is required as a practical matter, including patient condition and economic efficiency.

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—

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.

Requirement for payment.

This provision outlines the foundational requirements for home health services to qualify for Medicare payment, including provider participation and certification.

Beneficiary qualifications for coverage of services.

To qualify for Medicare coverage of home health services, a beneficiary must meet each of the following requirements:

Plan of care requirements.

This provision details the requirements for establishing, reviewing, and signing the individualized plan of care for home health services.

Skilled services requirements.

This provision establishes the clinical, documentation, and coverage criteria for skilled nursing, physical therapy, speech-language pathology, and occupational therapy services under Medicare.

Dependent services requirements.

This provision outlines the coverage requirements for home health dependent services, including home health aide, medical social services, occupational therapy, and medical supplies.

Allowable administrative costs.

Services that are allowable as administrative costs but are not separately billable include, but are not limited to, the following:

Place of service requirements.

This provision defines the permissible locations for furnishing covered home health services, including the beneficiary's home and specific outpatient settings.

Visits.

This provision defines the criteria for allowable home health visits under Medicare Part A and Part B, including the definition of a visit.

Excluded services.

This provision lists services that are excluded from coverage under the Medicare home health benefit, such as drugs, transportation, and housekeeping.

General description of benefits.

This provision provides a general overview of Medicare Part A hospital insurance benefits, including inpatient hospital, SNF, home health, and hospice care.

Coinsurance for durable medical equipment (DME) and applicable disposable devices furnished as a home health service.

This provision specifies the coinsurance liability for durable medical equipment and disposable devices provided as part of home health services.

Benefit periods.

Defines the start and end of Medicare benefit periods for inpatient hospital, critical access hospital, and skilled nursing facility services.

General limitations on amount of benefits.

Specifies the limits on Medicare benefit days for inpatient hospital, critical access hospital, skilled nursing facility, and home health services.

Lifetime maximum on inpatient psychiatric care.

There is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary.

Reduction of inpatient psychiatric benefit days available in the initial benefit period.

Outlines the rules for reducing available Medicare benefit days for inpatient psychiatric services based on pre-entitlement stays.

Services that are counted toward allowable amounts.

Establishes the criteria for counting inpatient days and home health visits toward Medicare benefit limits.

Lifetime reserve days.

This provision outlines the rules for beneficiary election regarding the use of Medicare lifetime reserve days, including filing requirements, deemed elections, and exceptions for prospective payment system stays.

Revocation of election not to use lifetime reserve days.

This provision establishes the process and timeframes for a beneficiary to revoke a previous election not to use Medicare lifetime reserve days.

Guarantee of payment for inpatient hospital or inpatient CAH services furnished before notification of exhaustion of benefits.

This provision specifies the conditions under which Medicare will guarantee payment for services rendered after a beneficiary has exhausted benefit days, provided the hospital was unaware of the exhaustion.

Inpatient deductible and coinsurance: General provisions.

This provision defines the general nature of inpatient deductibles and coinsurance as portions of hospital costs not covered by Medicare and subject to annual adjustment.

Inpatient hospital deductible.

This provision outlines the application of the inpatient hospital deductible, including its frequency of charge per benefit period and the timing of applicable rates.

Inpatient hospital coinsurance.

This provision defines the coinsurance amounts chargeable to beneficiaries for inpatient hospital care after the first 60 days of a benefit period.

Skilled nursing facility (SNF) care coinsurance.

This provision defines the coinsurance amounts chargeable to beneficiaries for skilled nursing facility care after the first 20 days of a benefit period.

Blood deductible.

This provision outlines the Medicare blood deductible requirements, including beneficiary responsibility for the first three units of whole blood or packed red cells and replacement criteria.

Exemption of kidney donors from deductible and coinsurance requirements.

Medicare deductible and coinsurance requirements are waived for services provided to individuals in connection with kidney donation for transplant surgery.