(Medicare General Information, Eligibility, and Entitlement)

A provider which is dissatisfied with the Secretary's determination terminating its agreement is entitled to request a hearing thereon in accordance with the appeals procedures contained in 42 CFR Part 498.  There is no reconsideration step before the opportunity for a hearing.  NOTE:   The involuntary termination of a hospital's approval authorizing it to provide extended care services, i.e., to be a swing bed facility, does not automatically result in the involuntary termination of the hospital's agreement relating to the provision of hospital services.   10.6.3 - Expiration and Renewal - Nonrenewal of SNF Term Agreements  (Rev. 1, 09-11-02)  All agreements with skilled nursing facilities are required to be for a specified term of up to 12 full calendar months with fixed expiration dates.  The agreement expires at the close of the last day of its specified term and is not automatically renewable from term to term.  When the term of an agreement is extended (see 10.6.3 of this chapter), the close of the last day of its specified term is the close of the day of the extension of the agreement.  Thus, when the term of an agreement is extended, the provider's participation in the program continues, and the agreement does not expire until the close of the last day to which it has been extended.  Since an agreement with a SNF is not automatically renewable from term to term, each term agreement with a SNF requires that the SNF qualify for participation and that its agreement be accepted for filing.  A participating SNF may, however, continue its participation under the agreement form previously accepted for filing, provided the SNF continues to qualify for participation and the agreement form is again accepted for filing and renewed for a term which begins on the date immediately following the close of the last day of the prior term of the agreement.  When the requirements for participation continue to be met, there is no limit to the number of times that the SNF's agreement form may again be accepted and renewed for a specified term.   When the time -limited agreement (including an agreement which has had its term extended) is renewed on the day immediately following the close of the last day of its term, the expiration of the agreement is not considered a termination of participation in the program.  However, once an agreement with a SNF is (1) not renewed, or (2) voluntarily terminated by the SNF, or (3) involuntarily terminated (including cancellations) by the Secretary, the previously accepted agreement cannot again be accepted and renewed.  In such cases, the SNF is required to execute and file a new agreement if it is again found eligible to participate in the Medicare program.  The effective date of the new agreement must be determined in accordance with regulatory provisions (42 CFR 489.13).   The Secretary's determination not to accept and renew a SNF agreement is a determination relating to the qualifications of the SNF in the period immediately following the close of the SNF's existing agreement and the SNF is entitled to request a reconsider ation of the determination in accordance with the appeals procedure contained in 42 CFR part 405, subpart 0.  Such determinations involve a finding that:    Based on a State agency resurvey and recertification, the SNF will not be approved for a period of certification because it is out of compliance with one or more requirements for participation;   Based on a State agency resurvey and recertification, the SNF continues to be out of compliance with the same standard(s) in the requirements for participation as were found out of compliance during the term of the agreement and the facility will not be ap proved for a new period of certification; or    The SNF has violated the terms of its agreement or the provisions of title XVIII or regulations promulgated thereunder.   In cases of nonrenewal by the Secretary, the A/B MAC (A)'s role is the same as for involuntary terminations.  10.6.4 - Determining Payment for Services Furnished After Termination of Provider Agreement  (Rev. 42, Issued: 11- 09-06, Effective: N/A, Implementation: 12 -11-06)  Effective with the date a provider agreement (or swing bed approval) terminates no payment is made to the provider under such agreement for the following:   A. Hospital   1. Termination -Hospital Agreement -  Inpatient hospital services (including inpatient psychiatric hospital services) and swing bed extended care services furnished on or after the effective date of the hospital's termination, except that payment can continue to be made for up to 30 days of inpatient hospital services and/or swing bed extended care services (total of no more than 30 days) furnished on or after the termination date to beneficiaries who were admitted (at either the acute or extended care level)  prior to the termination date.   2. Termination -Swing Bed Approval - Swing bed extended care services furnished on or after the effective date of the termination of the hospital's swing bed approval, except that payment can continue for up to 30 days of extended care services furnished on or after the termination date to beneficiaries who were admitted (at either the acute or extended care level) prior to the termination date.   B. Skilled Nursing Facility   1. Termination -SNF - Posthospital extended care services furnished on or after the effective date of termination of the agreement, where such agreement has been voluntarily terminated by the provider (see 10.6.1 of this chapter) or involuntarily terminated by the Secretary for cause (see 10.6.2 of this chapter), except that payment can continue to be made for up to 30 days of posthospital extended care services furnished on and after the termination date to beneficiaries who were admitted prior to the termination date.   C. HHA and Hospice   Payment may be made for services under a plan of treatment for up to 30 days following the effective termination date of a home health agency or hospice if the plan was established before the termination date.   D. Providers - Termination   See Medicare Claims Processing Manual Chapter 1 for billing instructions concerning other items and services, including outpatient physical therapy or speech-language pathology and diagnostic services, furnished on or after the effective date of termination on or after the day following the close of such agreement.  10.6.5 - Change of Provider Ownership  (Rev. 1, 09-11-02)  When an organization having a provider agreement undergoes a change of ownership, the agreement is automatically assigned to the new owner.  A participating provider which plans to change ownership should give advance notice of its intention so that necess ary action can be taken in the event the newly -owned institution does not wish to participate in the Medicare program.   A participating provider which plans to enter into a lease arrangement (in whole, or in part) should also give advance notice of its intention.  A change of ownership would occur for example:    Where a sole proprietor transfers title to an enterprise to another party;   Where, in the case of a partnership, the addition, removal, or substitution of a partner effects a termination of such partnership and creates a successor partnership or other entity;    Where an incorporated provider merges with an incorporated institution which is not participating in the program and the nonparticipating institution is the surviving corporation or where two or more corporate providers consolidate and such consolidation r esults in the creation of a new corporate entity; or    Where an unincorporated provider (a sole proprietorship or partnership) becomes incorporated.   Whenever A/B MACs (A) learn of an impending change of ownership, or possible change of ownership, they inform the regional office immediately.  They refer any questions they may have concerning change of ownership situations to the regional office.   20 - Hospital Defined  (Rev. 42, Issued: 11- 09-06, Effective: N/A, Implementation: 12 -11-06)  A hospital (other than psychiatric) means an institution which is primarily engaged in providing, by or under the supervision of physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons; or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.   To be eligible to participate in Medicare, a hospital must also be an institution which:    Maintains clinical records on all patients;   Has bylaws in effect with respect to its staff of physicians;   Has a requirement that every patient must be under the care of a physician;    Provides 24- hour nursing service rendered or supervised by a registered professional nurse, and has a licensed practical nurse or registered professional nurse on duty at all times;    Has in effect a hospital utilization review plan;    Is licensed or is approved by the State or local licensing agency as meeting the standards established for such licensing; and    Meets other health and safety requirements found necessary by the Secretary of Health, and Human Services.  (These additional requirements may not be higher than comparable ones prescribed for accreditation by the Joint Commission on Accreditation of Hospitals with exceptions specified in the law).  Such an institution, if approved to participate as a hospital, may also be approved as a swing bed facility pursuant to demonstration authority or if the hospital is a rural hospital with less than 100 beds. (See 30.3 below.)  20.1 - Definition of Emergency Inpatient and Outpatient Services  (Rev. 1, 09-11-02)  Payment may be made for certain Part A inpatient hospital services and Part B outpatient hospital services provided in a nonparticipating U.S. hospital where they are necessary to prevent the death or serious impairment of the health of the individual.  Be cause of the threat to the life or health of the individual, the use of the most accessible hospital equipped to furnish such services is necessary.  The determination of emergency services depends upon three separate findings:   The hospital meets the definition of an emergency hospital (see 20.2  of this chapter),    The services meet the definition of emergency services (see Claims Processing Manual, Chapter 3, 110), and    The hospital is substantially more accessible from the site of the emergency than is the nearest participating hospital.   20.2 - Definition of an Emergency Services Hospital  (Rev. 1, 09-11-02)  An emergency services hospital is a nonparticipating hospital which meets the requirements of the law's definition of a "hospital" relating to full-time nursing services and licensure under State or applicable local law.  (A Federal hospital need not be licensed under State or local licensing laws to meet the definition of emergency hospital.) In addition, the hospital must be primarily engaged in providing, under the supervision of doctors of medicine or osteopathy, services of the type that 20.1 describes in defining the term hospital, and must not be primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care. (See the definition of a SNF in 30 of this chapter.)  Psychiatric hospitals that meet these requirements can qualify as emergency hospitals.  Inpatient hospital services and related physician and ambulance services furnished outside the U.S. are covered under the limited conditions in Medicare Claims Processing Manual Chapter 1.  20.3 - Psychiatric Hospital  (Rev. 1, 09-11-02)  A psychiatric hospital is an institution which is primarily engaged in providing by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons.  To be eligible for participation in the program as a  psychiatric hospital, it must meet the Medicare conditions of participation for hospitals or be deemed to meet those conditions based on accreditation by the Joint Commission on Accreditation of Hospitals (JCAH), have a utilization review plan, and comply with additional staffing and medical record requirements necessary to carry out an active program of treatment and intensive care.   20.4 - Certification of Parts of Institutions as Hospital  (Rev. 1, 09- 11-02)  Under certain conditions a distinct part of a psychiatric institution may be certified as a psychiatric or general hospital.  20.5 - Part of a Psychiatric Institutions as a Psychiatric Hospital  (Rev. 1, 09- 11-02)  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)