(Medicare General Information, Eligibility, and Entitlement)

A distinct part of a psychiatric institution can be certified as a psychiatric hospital if it meets the conditions of participation even though the institution of which it is a part does not.  If the distinct part meets requirements equivalent to the accre ditation requirements of the JCAH, it can qualify under the program even though the institution itself is not accredited.   20.6 - General Hospital Facility of Psychiatric Hospital  (Rev. 1, 09- 11-02)  A general hospital facility within a psychiatric hospital may be certified as a general hospital independent of the institution as a whole provided the general facility is a self -contained operational entity distinct from the rest of the institution.  The general hospital facility would be regarded as a separate institution for this purpose since the law does not provide for certifying a "distinct part' of an institution as a general hospital.  Services furnished in a separately certified general hospital facility are not subject to any of the benefit limitations applicable to the other parts of the in stitution, i.e., the reduction in benefit days in the first spell of illness and the 190- day lifetime maximum on inpatient services in psychiatric hospitals.   20.7 - Part of a General Hospital as a Psychiatric Hospital  (Rev. 1, 09- 11-02)  There is no provision for a psychiatric wing of a general hospital to be certified as a psychiatric hospital.  The distinct part provisions apply only to psychiatric institutions and not to general hospitals.  However, this does not prevent the certificati on of a psychiatric hospital which is a part of a medical center or other large complex, provided the hospital operates as a separate functioning entity, i.e., it is located in a separate building, wing, or part of a building, has its own administration and maintains separate fiscal records.   30 - Skilled Nursing Facility Defined  (Rev. 1, 09-11-02)  A SNF is an institution or a distinct part of an institution (see 30.1 of this chapter), such as a skilled nursing home or rehabilitation center, which has a transfer agreement in effect with one or more participating hospitals (see 30.2 of this chapter for transfer agreements and 10.1  of this chapter, for definition of a participating hospital) and which:   Is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and    Meets the requirements for participation in 1819(a) through 1819 (d) as amended by 4201 of OBRA 1987 of the Social Security Act and in regulations at 42 CFR 483, B.  A qualified SNF is one that meets all the requirements in the preceding definition.  For Medicare purposes, the term SNF does not include any institution which is primarily for the care and treatment of mental diseases.  (This restriction does not apply to title XIX (Medicaid)).  Also, the term "skilled nursing facility" does not include swing bed hospitals authorized to provide and be paid for extended care services.  Swing bed hospitals must meet many of the same requirements that apply to SNFs (for more details regarding swing bed hospitals, see 30.3.)  30.1 - Distinct Part of an Institution as a SNF  (Rev. 1, 09-11-02)  The term "distinct part" refers to a portion of an institution or institutional complex (e.g., a nursing home or a hospital) that is certified to provide SNF and/or Nursing Facility (NF) services.  To qualify for participation in the program as a distinct part SNF of an institution, it must be physically separate from the rest of the institution, i.e., it must represent an entire physically identifiable unit consisting of all the beds within that unit, such as a separate building, floor, wing, or ward.  A distinct part must be fiscally separate for cost reporting purposes.  Although it is required that the distinct part be identifiable as a separate unit within the institution , it need not necessarily be confined to a single location within the institution's physical plant.  The distinct part may, for example, consist of several floors or wards which are scattered throughout several different buildings within the institutional complex.  In each case, however, the patients of the distinct part must be located in units which are physically separate from those units housing all other patients of the institution.  Various beds scattered throughout the institution do not comprise a distinct part for purposes of being approved by Medicare as a SNF.   An institution or institutional complex can only be certified with one distinct part SNF and/or one distinct part NF.  A hospital-based SNF is by definition a distinct part. Multiple certifications within the same institution or institutional complex are strictly prohibited.  The distinct part must consist of all beds within the designated area.  Where an institution or institutional complex owns and operates a SNF and/or a NF distinct part, that SNF and/or NF distinct part is a single distinct part even if  it is operated at various locations throughout the institution or institutional complex.  The aggregate of the SNF and/or NF locations represents a single distinct part subprovider, not multiple subproviders, and must be assigned a single provider number.   30.2 - Transfer Agreements  (Rev. 114, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)  To participate in the program, a SNF must have a written transfer agreement with one or more participating hospitals (see 10.1 of this chapter) providing for the transfer of patients between the hospital and the SNF, and for the interchange of medical and other information.  If an otherwise qualified SNF has attempted in good faith, but without success, to enter into a transfer agreement, this requirement may be waived by the State agency.  (See 42 CFR 483.70(j) for the detailed requirements for transfer agreements.)  30.3 - Hospital Providers of Extended Care Services  (Rev.114, Issued: 03-16- 18, Effective: 06 -19-18, Implementation: 06-19-18)  In order to address the shortage of rural SNF beds for Medicare patients, rural hospitals with fewer than 100 beds may be reimbursed under Medicare Part A for furnishing post hospital extended care services to Medicare beneficiaries if the hospital has obtained a swing bed approval from the Department of Health and Human Services.  Such a hospital, known as a swing bed hospital, can "swing" its beds between hospital and SNF levels of care, on an as needed basis.  In accordance with 1883 of the Act, rural hospitals with fewer than 100 beds must make application and request approval to be a swing bed hospital from the regional office.  In order to obtain swing bed approval, the hospital must:    As noted above, be located in a rural area (i.e., located outside of an "urbanized area," as defined by the Census Bureau and based on the most recent census, see 42 CFR 482.58(a)(2)) and have fewer than 100 beds (excluding intensive care-type beds and newborn bassinets)   Have a Medicare provider agreement, as a hospital;    Be substantially in compliance with the SNF participation requirements identified in 42 CFR 482.58; (most other SNF participation requirements would be largely met by virtue of the facility's compliance with comparable hospital conditions);   Not have in effect a 24 -hour nursing waiver granted under 42 CFR 488.54(c); and    Not have had a swing bed approval terminated within the 2 years previous to application for swing bed participation.  However, the Department may grant swing bed approval, on a demonstration basis, with hospitals meeting all of the statutory requirements except bed size and geographic location.  Prior to October 1, 1990, a swing- bed hospital could also furnish intermediate care facility (ICF) type services to non -Medicare patients.  Effective with services furnished on or after October 1, 1990, the distinction between SNFs and ICFs for certifying a facility for the Medicaid program was eliminated.  Thus, for purposes of the Medicaid program, facilities may no longer be certified as ICFs but instead may be certified only as nursing facilities (NFs) and can provide services as defined in 1919(a)(1) of the Act.  Effective October 1, 1990, such services furnished by swing- bed hospitals to Medicaid and to other non- Medicare patients are referred to as NF -type services.   See 10.3 of Pub. 100- 02, Medicare Benefit Policy Manual, chapter 8, for additional information on Part A coverage of SNF -level swing -bed services as extended care services.   40 - Religious Nonmedical Health Care Institution Defined  (Rev. 35, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  In order for a Medicare or Medicaid provider to meet the definition of an RNHCI, it must satisfy the ten qualifying provisions as contained in Section 1861(ss)(1) of the Act. Section 1861(ss)(1) of the Act states that an RNHCI means an institution that:   1. Is described in Subsection (c)(3) of Section 501 of the Internal Revenue Code of 1986 and is exempt from taxes under Subsection (a) of that section.  The inability to either gain or retain this status will disqualify an institution from participation as  an RNHCI.   2. Is lawfully operated under all applicable Federal, State, and local laws and regulations.  Federal law supersedes State and local laws unless the State and local requirements are more stringent than the Federal requirements.   3. Furnishes only nonmedical nursing items and services to patients who choose to rely solely upon a religious method of healing and for whom the acceptance of medical services would be inconsistent with their religious beliefs.  Medicare does not cover the religious component of the healing.  4. Furnishes nonmedical items and services exclusively through nonmedical nursing personnel who are experienced in caring for the physical needs of these patients.  This care frequently involves: assistance in moving, turning, positioning, and ambulation; meeting nutritional needs; and comfort and support measures.   5. Furnishes nonmedical items and services to inpatients on a 24- hour basis.  6. Does not furnish, on the basis of its religious beliefs, through its personnel or otherwise, medical items and services (including any medical screening, examination, diagnosis, prognosis, treatment, or the administration of drugs) for its patients.   7. Is not owned by, under common ownership with, or has an ownership interest of 5 percent or more in, a provider of medical treatment or services, and is not affiliated with a provider of medical treatment or services, or with an individual who has an own ership interest of 5 percent or more in, a provider of medical treatment or services.  For purposes of this requirement, an affiliation does not exist in the circumstances described in Section 1861(ss)(4) of the Act or 42 CFR 403.738(c).   8. Has in effect a utilization review plan that:    Provides for review of admissions to the institution, of the duration of stays, of cases of continuous extended duration, and of the items and services furnished by the institution;    Requires that the reviews be made by an appropriate committee of the institution that includes the individuals responsible for overall administration and for supervision of nursing personnel at the institution;    Provides that records be maintained of the meetings, decisions, and actions of the committee; and    Meets other requirements as the Secretary finds necessary to establish an effective utilization review plan.   9. Provides information the Secretary may require to implement Section 1821 of the Act, including information relating to quality of care and coverage determinations.   10. Meets other requirements the Secretary finds necessary in the interest of the health and safety of individuals who are furnished services in the institution.  These requirements include the conditions of participation in 42 CFR 403, Subpart G. An RNHCI must meet or exceed the conditions of participation in order to qualify as a Medicare provider.  The RNHCI must also have a valid provider agreement with CMS.   50 - Home Health Agency Defined  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  A home health agency is a public agency or private organization, or a subdivision of such an agency or organization, which meets the following requirements:    It is primarily engaged in providing skilled nursing services and other therapeutic services, such as physical therapy, occupational therapy, or speech -language pathology, medical social services, and home health aide services.  A public or voluntary nonpr ofit health agency may qualify by:   o Furnishing both skilled nursing and at least one other therapeutic service directly to patients, or   o Furnishing directly either skilled nursing services or at least one other therapeutic service and having arrangements with another public or voluntary nonprofit agency to furnish the services which it does not provide directly.   NOTE:   A proprietary agency can qualify only by providing directly both skilled nursing services and at least one other therapeutic service.    It has policies established by a professional group associated with the agency or organization (including at least one physician and at least one registered professional nurse) to govern the services, and provides for supervision of such services by a phys ician or a registered professional nurse;    It maintains clinical records on all patients;   It is licensed in accordance with State or local law or is approved by the State or local licensing agency as meeting the licensing standards (where State or local law provides for the licensing of such agencies or organizations); and