Social Security Act §1861

Part EMiscellaneous ProvisionsDEFINITIONS OF SERVICES, INSTITUTIONS, ETC.[495]Sec.1861.[42 U.S.C. 1395x]For purposesof this titleSpell of Illness(a)The term spell of illness withrespect to any individual means a period of consecutive days(1)beginning withthe first day (not included in a previous spell of illness) (A) onwhich such individual is furnished inpatient hospital services, inpatientcritical access hospital services or extended care services, and (B)which occurs in a month for which he is entitled to benefits underpart A, and(2)ending with theclose of the first period of 60 consecutive days thereafter on eachof which he is neither an inpatient of a hospital or critical accesshospital nor an inpatient of a facility described in section 1819(a)(1) or subsection(y)(1).Inpatient Hospital Services(b)The term inpatient hospital services means the following items and services furnished to an inpatientof a hospital and (except as provided in paragraph (3)) by the hospital(1)bed and board;(2)such nursing servicesand other related services, such use of hospital facilities, and suchmedical social services as are ordinarily furnished by the hospitalfor the care and treatment of inpatients, and such drugs, biologicals,supplies, appliances, and equipment, for use in the hospital, as areordinarily furnished by such hospital for the care and treatment ofinpatients; and(3)such other diagnosticor therapeutic items or services, furnished by the hospital or byothers under arrangements with them made by the hospital, as are ordinarilyfurnished to inpatients either by such hospital or by others undersuch arrangements;excluding, however(4)medical or surgicalservices provided by a physician, resident, or intern, services describedby subsection (s)(2)(K), certified nurse-midwife services, qualifiedpsychologist services, and services of a certified registered nurseanesthetist; and(5)the services ofa private-duty nurse or other private-duty attendant.Paragraph (4) shall not apply to services provided in a hospitalby(6)an intern or aresident-in-training under a teaching program approved by the Councilon Medical Education of the American Medical Association or, in thecase of an osteopathic hospital, approved by the Committee on Hospitalsof the Bureau of Professional Education of the American OsteopathicAssociation, or, in the case of services in a hospital or osteopathichospital by an intern or resident-in-training in the field of dentistry,approved by the Council on Dental Education of the American DentalAssociation, or in the case of services in a hospital or osteopathichospital by an intern or resident-in-training in the field of podiatry,approved by the Council on Podiatric Medical Education of the AmericanPodiatric Medical Association; or(7)a physician wherethe hospital has a teaching program approved as specified in paragraph(6), if (A) the hospital elects to receive any payment due under thistitle for reasonable costs of such services, and (B) all physiciansin such hospital agree not to bill charges for professional servicesrendered in such hospital to individuals covered under the insuranceprogram established by this title.Inpatient Psychiatric Hospital Services(c)The term inpatient psychiatric hospitalservices means inpatient hospital services furnished to aninpatient of a psychiatric hospital.Supplier(d)The term supplier means, unlessthe context otherwise requires, a physician or other practitioner,a facility, or other entity (other than a provider of services) thatfurnishes items or services under this title.Hospital(e)The term hospital (except forpurposes of sections 1814(d), 1814(f), and 1835(b), subsection (a)(2) of this section, paragraph (7)of this subsection, and subsection (i) of this section) means an institutionwhich(1)is primarily engagedin providing, by or under the supervision of physicians, to inpatients(A) diagnostic services and therapeutic services for medical diagnosis,treatment, and care of injured, disabled, or sick persons, or (B)rehabilitation services for the rehabilitation of injured, disabled,or sick persons;(2)maintains clinicalrecords on all patients;(3)has bylaws ineffect with respect to its staff of physicians;(4)has a requirementthat every patient with respect to whom payment may be made underthis title must be under the care of a physician except that a patientreceiving qualified psychologist services (as defined in subsection(ii)) may be under the care of a clinical psychologist with respectto such services to the extent permitted under State law;(5)provides 24-hournursing service rendered or supervised by a registered professionalnurse, and has a licensed practical nurse or registered professionalnurse on duty at all times; except that until January 1, 1979, theSecretary is authorized to waive the requirement of this paragraphfor any one-year period with respect to any institution, insofar assuch requirement relates to the provision of twenty-four-hour nursingservice rendered or supervised by a registered professional nurse(except that in any event a registered professional nurse must bepresent on the premises to render or supervise the nursing serviceprovided, during at least the regular daytime shift), where immediatelypreceding such one-year period he finds that(A)such institutionis located in a rural area and the supply of hospital services insuch area is not sufficient to meet the needs of individuals residingtherein,(B)the failureof such institution to qualify as a hospital would seriously reducethe availability of such services to such individuals, and(C)such institutionhas made and continues to make a good faith effort to comply withthis paragraph, but such compliance is impeded by the lack of qualifiednursing personnel in such area;(6)(A)has in effecta hospital utilization review plan which meets the requirements ofsubsection (k) and(B)has in placea discharge planning process that meets the requirements of subsection(ee);(7)in the case ofan institution in any State in which State or applicable local lawprovides for the licensing of hospitals, (A) is licensed pursuantto such law or (B) is approved, by the agency of such State or localityresponsible for licensing hospitals, as meeting the standards establishedfor such licensing;(8)has in effectan overall plan and budget that meets the requirements of subsection(z); and(9)meets such otherrequirements as the Secretary finds necessary in the interest of thehealth and safety of individuals who are furnished services in theinstitution.For purposes of subsection (a)(2), such term includes any institutionwhich meets the requirements of paragraph (1) of this subsection.For purposes of sections 1814(d) and 1835(b) (including determinationof whether an individual received inpatient hospital services or diagnosticservices for purposes of such sections), section 1814(f)(2), and subsection (i) ofthis section, such term includes any institution which (i) meets therequirements of paragraphs (5) and (7) of this subsection, (ii) isnot primarily engaged in providing the services described in section 1861(j)(1)(A) and(iii) is primarily engaged in providing, by or under the supervisionof individuals referred to in paragraph (1) of section 1861(r), to inpatientsdiagnostic services and therapeutic services for medical diagnosis,treatment, and care of injured, disabled, or sick persons, or rehabilitationservices for the rehabilitation of injured, disabled, or sick persons.For purposes of section 1814(f)(1), such term includes an institution which (i) isa hospital for purposes of sections 1814(d), 1814(f)(2), and 1835(b) and (ii) is accredited by theJoint Commission on Accreditation of Hospitals, or is accredited byor approved by a program of the country in which such institutionis located if the Secretary finds the accreditation or comparableapproval standards of such program to be essentially equivalent tothose of the Joint Commission on Accreditation of Hospitals. Notwithstandingthe preceding provisions of this subsection, such term shall not,except for purposes of subsection (a)(2), include any institutionwhich is primarily for the care and treatment of mental diseases unlessit is a psychiatric hospital (as defined in subsection (f)). The term hospital also includes a religious nonmedical health careinstitution (as defined in subsection (ss)(1)), with respect to itemsand services ordinarily furnished by such institution to inpatients,and payment may be made with respect to services provided by or insuch an institution only to such extent and under such conditions,limitations, and requirements (in addition to or in lieu of the conditions,limitations, and requirements otherwise applicable) as may be providedin regulations consistent with section 1821. For provisions deeming certain requirementsof this subsection to be met in the case of accredited institutions,see section 1865. The term hospital also includes a facility of fiftybeds or less which is located in an area determined by the Secretaryto meet the definition relating to a rural area described in subparagraph(A) of paragraph (5) of this subsection and which meets the otherrequirements of this subsection, except that(A)with respectto the requirements for nursing services applicable after December31, 1978, such requirements shall provide for temporary waiver ofthe requirements, for such period as the Secretary deems appropriate,where (i) the facilitys failure to fully comply with the requirementsis attributable to a temporary shortage of qualified nursing personnelin the area in which the facility is located, (ii) a registered professionalnurse is present on the premises to render or supervise the nursingservice provided during at least the regular daytime shift, and (iii)the Secretary determines that the employment of such nursing personnelas are available to the facility during such temporary period willnot adversely affect the health and safety of patients;(B)with respectto the health and safety requirements promulgated under paragraph(9), such requirements shall be applied by the Secretary to a facilityherein defined in such manner as to assure that personnel requirementstake into account the availability of technical personnel and theeducational opportunities for technical personnel in the area in whichsuch facility is located, and the scope of services rendered by suchfacility; and the Secretary, by regulations, shall provide for thecontinued participation of such a facility where such personnel requirementsare not fully met, for such period as the Secretary determines that(i) the facility is making good faith efforts to fully comply withthe personnel requirements, (ii) the employment by the facility ofsuch personnel as are available to the facility will not adverselyaffect the health and safety of patients, and (iii) if the Secretaryhas determined that because of the facilitys waiver under thissubparagraph the facility should limit its scope of services in ordernot to adversely affect the health and safety of the facilityspatients, the facility is so limiting the scope of services it provides;and(C)with respectto the fire and safety requirements promulgated under paragraph (9),the Secretary (i) may waive, for such period as he deems appropriate,specific provisions of such requirements which if rigidly appliedwould result in unreasonable hardship for such a facility and which,if not applied, would not jeopardize the health and safety of patients,and (ii) may accept a facilitys compliance with all applicableState codes relating to fire and safety in lieu of compliance withthe fire and safety requirements promulgated under paragraph (9),if he determines that such State has in effect fire and safety codes,imposed by State law, which adequately protect patients.The term hospital does not include, unless thecontext otherwise requires, a critical access hospital (as definedin section 1861(mm)(1)).Psychiatric Hospital(f)The term psychiatric hospital means an institution which(1)is primarily engagedin providing, by or under the supervision of a physician, psychiatricservices for the diagnosis and treatment of mentally ill persons;(2)satisfies therequirements of paragraphs (3) through (9) of subsection (e);(3)maintains clinicalrecords on all patients and maintains such records as the Secretaryfinds to be necessary to determine the degree and intensity of thetreatment provided to individuals entitled to hospital insurance benefitsunder part A; and(4)meets such staffingrequirements as the Secretary finds necessary for the institutionto carry out an active program of treatment for individuals who arefurnished services in the institution.In the case of an institution which satisfies paragraphs (1)and (2) of the preceding sentence and which contains a distinct partwhich also satisfies paragraphs (3) and (4) of such sentence, suchdistinct part shall be considered to be a psychiatric hospital.Outpatient Occupational Therapy Services(g)The term outpatient occupational therapyservices has the meaning given the term outpatientphysical therapy services in subsection (p), except that occupational shall be substituted for physical each place it appears therein.Extended Care Services(h)The term extended care services means the following items and services furnished to an inpatientof a skilled nursing facility and (except as provided in paragraphs(3), (6), and (7)) by such skilled nursing facility(1)nursing care providedby or under the supervision of a registered professional nurse;(2)bed and boardin connection with the furnishing of such nursing care;