evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
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
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
 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)
(Medicare General Information, Eligibility, and Entitlement)
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)  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:
(Medicare General Information, Eligibility, and Entitlement)
 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.)
(Medicare General Information, Eligibility, and Entitlement)
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
(Medicare General Information, Eligibility, and Entitlement)
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.)
(Medicare General Information, Eligibility, and Entitlement)
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
(Medicare General Information, Eligibility, and Entitlement)
 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.
(Medicare General Information, Eligibility, and Entitlement)
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.