Social Security Act §1861

(C)For provisionsrestricting payment for provider-based physicians servicesand for payments under certain percentage arrangements, see section 1887.(D)For furtherlimitations on reasonable cost and determination of payment amountsfor routine service costs of skilled nursing facilities, see subsections(a) through (c) of section 1888.(8)Items unrelatedto patient careReasonable costs do not include costs for thefollowing(i)entertainment,including tickets to sporting and other entertainment events;(ii)gifts or donations;(iii)personal useof motor vehicles;(iv)costs for finesand penalties resulting from violations of Federal, State, or locallaws; and(v)education expensesfor spouses or other dependents of providers of services, their employeesor contractors.Arrangements for Certain Services(w)(1)The term arrangements is limited to arrangements under which receiptof payment by the hospital, critical access hospital, skilled nursingfacility, home health agency, or hospice program (whether in its ownright or as agent), with respect to services for which an individualis entitled to have payment made under this title, discharges theliability of such individual or any other person to pay for the services.(2)Utilization reviewactivities conducted, in accordance with the requirements of the programestablished under part B of title XI of the Social Security Act withrespect to services furnished by a hospital or critical access hospitalto patients insured under part A of this title or entitled to havepayment made for such services under part B of this title or undera State plan approved under title XIX, by a quality improvement[524]organization designated for the areain which such hospital or critical access hospital is located shallbe deemed to have been conducted pursuant to arrangements betweensuch hospital or critical access hospital and such organization underwhich such hospital or critical access hospital is obligated to payto such organization, as a condition of receiving payment for hospitalor critical access hospital services so furnished under this partor under such a State plan, such amount as is reasonably incurredand requested (as determined under regulations of the Secretary) bysuch organization in conducting such review activities with respectto services furnished by such hospital or critical access hospitalto such patients.State and United States(x)The terms State and UnitedStates have the meaning given to them by subsections (h) and(i), respectively, of section 210.Extended Care in Religious Nonmedical Health Care Institutions(y)(1)The term skilled nursing facility also includes a religious nonmedicalhealth care institution (as defined in subsection (ss)(1)), (exceptfor purposes of subsection (a)(2)) with respect to items and servicesordinarily furnished by such an institution to inpatients, and paymentmay be made with respect to services provided by or in such an institutiononly to such extent and under such conditions, limitations, and requirements(in addition to or in lieu of the conditions, limitations, and requirementsotherwise applicable) as may be provided in regulations.(2)Notwithstandingany other provision of this title, payment under part A may not bemade for services furnished an individual in a skilled nursing facilityto which paragraph (1) applies unless such individual elects, in accordancewith regulations, for a spell of illness to have such services treatedas post-hospital extended care services for purposes of such part;and payment under part A may not be made for post-hospital extendedcare services(A)furnishedan individual during such spell of illness in a skilled nursing facilityto which paragraph (1) applies after(i)such serviceshave been furnished to him in such a facility for 30 days during suchspell, or(ii)such serviceshave been furnished to him during such spell in a skilled nursingfacility to which such paragraph does not apply; or(B)furnishedan individual during such spell of illness in a skilled nursing facilityto which paragraph (1) does not apply after such services have beenfurnished to him during such spell in a skilled nursing facility towhich such paragraph applies.(3)The amount payableunder part A for post-hospital extended care services furnished anindividual during any spell of illness in a skilled nursing facilityto which paragraph (1) applies shall be reduced by a coinsurance amountequal to one-eighth of the inpatient hospital deductible for eachday before the 31st day on which he is furnished such services insuch a facility during such spell (and the reduction under this paragraphshall be in lieu of any reduction under section 1813(a)(3)).(4)For purposes ofsubsection (i), the determination of whether services furnished byor in an institution described in paragraph (1) constitute post-hospitalextended care services shall be made in accordance with and subjectto such conditions, limitations, and requirements as may be providedin regulations.Institutional Planning(z)An overall plan and budget of a hospital, skillednursing facility, comprehensive outpatient rehabilitation facility,or home health agency shall be considered sufficient if it(1)provides for anannual operating budget which includes all anticipated income andexpenses related to items which would, under generally accepted accountingprinciples, be considered income and expense items (except that nothingin this paragraph shall require that there be prepared, in connectionwith any budget, an item-by-item identification of the componentsof each type of anticipated expenditure or income);(2)(A)providesfor a capital expenditures plan for at least a 3-year period (includingthe year to which the operating budget described in paragraph (1)is applicable) which includes and identifies in detail the anticipatedsources of financing for, and the objectives of, each anticipatedexpenditure in excess of $600,000 (or such lesser amount as may beestablished by the State under section 1122(g)(1) in which the hospital islocated) related to the acquisition of land, the improvement of land,buildings, and equipment, and the replacement, modernization, andexpansion of the buildings and equipment which would, under generallyaccepted accounting principles, be considered capital items;(B)providesthat such plan is submitted to the agency designated under section 1122(b), or if nosuch agency is designated, to the appropriate health planning agencyin the State (but this subparagraph shall not apply in the case ofa facility exempt from review under section 1122 by reason of section 1122(j));(3)provides for reviewand updating at least annually; and(4)is prepared, underthe direction of the governing body of the institution or agency,by a committee consisting of representatives of the governing body,the administrative staff, and the medical staff (if any) of the institutionor agency.Rural Health Clinic Services and Federally Qualified HealthCenter Services(aa)(1)The term rural health clinic services means(A)physiciansservices and such services and supplies as are covered under section 1861(s)(2)(A) iffurnished as an incident to a physicians professional serviceand items and services described in section 1861(s)(10),(B)such servicesfurnished by a physician assistant or a nurse practitioner (as definedin paragraph (5)), by a clinical psychologist (as defined by the Secretary)or by a clinical social worker (as defined in subsection (hh)(1)),and such services and supplies furnished as an incident to his serviceas would otherwise be covered if furnished by a physician or as anincident to a physicians service, and(C)in the caseof a rural health clinic located in an area in which there existsa shortage of home health agencies, part-time or intermittent nursingcare and related medical supplies (other than drugs and biologicals)furnished by a registered professional nurse or licensed practicalnurse to a homebound individual under a written plan of treatment(i) established and periodically reviewed by a physician describedin paragraph (2)(B), or (ii) established by a nurse practitioner orphysician assistant and periodically reviewed and approved by a physiciandescribed in paragraph (2)(B),when furnished to an individual as an outpatient of a ruralhealth clinic.(2)The term rural health clinic means a facility which(A)is primarilyengaged in furnishing to outpatients services described in subparagraphs(A) and (B) of paragraph (1);(B)in the caseof a facility which is not a physician-directed clinic, has an arrangement(consistent with the provisions of State and local law relative tothe practice, performance, and delivery of health services) with oneor more physicians (as defined in subsection (r)(1)) under which provisionis made for the periodic review by such physicians of covered servicesfurnished by physician assistants and nurse practitioners, the supervisionand guidance by such physicians of physician assistants and nursepractitioners, the preparation by such physicians of such medicalorders for care and treatment of clinic patients as may be necessary,and the availability of such physicians for such referral of and consultationfor patients as is necessary and for advice and assistance in themanagement of medical emergencies; and, in the case of a physician-directedclinic, has one or more of its staff physicians perform the activitiesaccomplished through such an arrangement;(C)maintainsclinical records on all patients;(D)has arrangementswith one or more hospitals, having agreements in effect under section 1866, for the referraland admission of patients requiring inpatient services or such diagnosticor other specialized services as are not available at the clinic;(E)has writtenpolicies, which are developed with the advice of (and with provisionfor review of such policies from time to time by) a group of professionalpersonnel, including one or more physicians and one or more physicianassistants or nurse practitioners, to govern those services describedin paragraph (1) which it furnishes;(F)has a physician,physician assistant, or nurse practitioner responsible for the executionof policies described in subparagraph (E) and relating to the provisionof the clinics services;(G)directlyprovides routine diagnostic services, including clinical laboratoryservices, as prescribed in regulations by the Secretary, and has promptaccess to additional diagnostic services from facilities meeting requirementsunder this title;(H)in compliancewith State and Federal law, has available for administering to patientsof the clinic at least such drugs and biologicals as are determinedby the Secretary to be necessary for the treatment of emergency cases(as defined in regulations) and has appropriate procedures or arrangementsfor storing, administering, and dispensing any drugs and biologicals;(I)has a qualityassessment and performance improvement program, and appropriate proceduresfor review of utilization of clinic services, as the Secretary mayspecify;(J)has a nursepractitioner, a physician assistant, or a certified nurse-midwife(as defined in subsection (gg)) available to furnish patient careservices not less than 50 percent of the time the clinic operates;and(K)meets suchother requirements as the Secretary may find necessary in the interestof the health and safety of the individuals who are furnished servicesby the clinic.