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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
Social Security Act §1861
(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)).
Social Security Act §1861
(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
Social Security Act §1861
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);
Social Security Act §1861
(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;
Social Security Act §1861
(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.
Social Security Act §1861
For the purposes of this title, such term includes only a facilitywhich (i) is located in an area that is not an urbanized area (asdefined by the Bureau of the Census) and in which there are insufficientnumbers of needed health care practitioners (as determined by theSecretary), and that, within the previous 4-year period, has beendesignated by the chief executive officer of the State and certifiedby the Secretary as an area with a shortage of personal health servicesor designated by the Secretary either (I) as an area with a shortageof personal health services under section 330(b)(3) or 1302(7) ofthe Public Health Service Act, (II) as a health professional shortagearea described in section 332(a)(1)(A) of that Act because of itsshortage of primary medical care manpower, (III) as a high impactarea described in section 329(a)(5) of that Act, of (IV) as an areawhich includes a population group which the Secretary determines hasa health manpower shortage under section 332(a)(1)(B) of that Act[525], (ii) has filed an agreement with theSecretary by which it agrees not to charge any individual or otherperson for items or services for which such individual is entitledto have payment made under this title, except for the amount of anydeductible or coinsurance amount imposed with respect to such itemsor services (not in excess of the amount customarily charged for suchitems and services by such clinic), pursuant to subsections (a) and(b) of section 1833, (iii) employs a physician assistant or nurse practitioner, and(iv) is not a rehabilitation agency or a facility which is primarilyfor the care and treatment of mental diseases. A facility that isin operation and qualifies as a rural health clinic under this titleor title XIX and that subsequently fails to satisfy the requirementof clause (i) shall be considered, for purposes of this title andtitle XIX, as still satisfying the requirement of such clause if itis determined, in accordance with criteria established by the Secretaryin regulations, to be essential to the delivery of primary care servicesthat would otherwise be unavailable in the geographic area servedby the clinic. If a State agency has determined under section 1864(a) that a facilityis a rural health clinic and the facility has applied to the Secretaryfor approval as such a clinic,
Social Security Act §1861
servicesthat would otherwise be unavailable in the geographic area servedby the clinic. If a State agency has determined under section 1864(a) that a facilityis a rural health clinic and the facility has applied to the Secretaryfor approval as such a clinic, the Secretary shall notify the facilityof the Secretarys approval or disapproval later than 60 daysafter the date of the State agency determination or the application(whichever is later).
Social Security Act §1861
(3)The term Federally qualified health center services means(A)servicesof the type described in subparagraphs (A) through (C) of paragraph(1) and preventive services (as defined in section 1861(ddd)(3));and(B)preventiveprimary health services that a center is required to provide undersection 330 of the Public Health Service Act,[526]when furnished to an individual as an outpatient of a Federallyqualified health center and, for this purpose, any reference to arural health clinic or a physician described in paragraph (2)(B) isdeemed a reference to a Federally qualified health center by the centeror by a health care professional under contract with the center ora physician at the center, respectively.(4)The term Federally qualified health center means an entity which(A)(i)is receivinga grant under section 330 of the Public Health Service Act, or(ii)(I)is receivingfunding from such a grant under a contract with the recipient of sucha grant, and (II) meets the requirements to receive a grant undersection 330 of such Act;(B)based onthe recommendation of the Health Resources and Services Administrationwithin the Public Health Service, is determined by the Secretary tomeet the requirements for receiving such a grant;(C)was treatedby the Secretary, for purposes of part B, as a comprehensive Federallyfunded health center as of January 1, 1990; or(D)is an outpatienthealth program or facility operated by a tribe or tribal organizationunder the Indian Self-Determination Act or by an urban Indian organizationreceiving funds under title V of the Indian Health Care ImprovementAct[527].(5)(A)The term physician assistant and the term nurse practitioner mean, for purposes of this title, a physician assistant or nursepractitioner who performs such services as such individual is legallyauthorized to perform (in the State in which the individual performssuch services) in accordance with State law (or the State regulatorymechanism provided by State law), and who meets such training, education,and experience requirements (or any combination thereof) as the Secretarymay prescribe in regulations.(B)The term clinical nurse specialist means, for purposes of this title,an individual who
Social Security Act §1861
(B)The term clinical nurse specialist means, for purposes of this title,an individual who(i)is a registerednurse and is licensed to practice nursing in the State in which theclinical nurse specialist services are performed; and(ii)holds a mastersdegree in a defined clinical area of nursing from an accredited educationalinstitution.(6)The term collaboration means a process in which a nurse practitionerworks with a physician to deliver health care services within thescope of the practitioners professional expertise, with medicaldirection and appropriate supervision as provided for in jointly developedguidelines or other mechanisms as defined by the law of the Statein which the services are performed.(7)(A)The Secretaryshall waive for a 1-year period the requirements of paragraph (2)that a rural health clinic employ a physician assistant, nurse practitioneror certified nurse midwife or that such clinic require such providersto furnish services at least 50 percent of the time that the clinicoperates for any facility that requests such waiver if the facilitydemonstrates that the facility has been unable, despite reasonableefforts, to hire a physician assistant, nurse practitioner, or certifiednurse-midwife in the previous 90-day period.(B)The Secretarymay not grant such a waiver under subparagraph (A) to a facility ifthe request for the waiver is made less than 6 months after the dateof the expiration of any previous such waiver for the facility, orif the facility has not yet been determined to meet the requirements(including subparagraph (J) of the first sentence of paragraph (2))of a rural health clinic.(C)A waiverwhich is requested under this paragraph shall be deemed granted unlesssuch request is denied by the Secretary within 60 days after the datesuch request is received.Services of a Certified Registered Nurse Anesthetist(bb)(1)The term services of a certified registered nurse anesthetist meansanesthesia services and related care furnished by a certified registerednurse anesthetist (as defined in paragraph (2)) which the nurse anesthetistis legally authorized to perform as such by the State in which theservices are furnished.
Social Security Act §1861
(2)The term certified registered nurse anesthetist means a certifiedregistered nurse anesthetist licensed by the State who meets sucheducation, training, and other requirements relating to anesthesiaservices and related care as the Secretary may prescribe. In prescribingsuch requirements the Secretary may use the same requirements as thoseestablished by a national organization for the certification of nurseanesthetists. Such term also includes, as prescribed by the Secretary,an anesthesiologist assistant.Comprehensive Outpatient Rehabilitation Facility Services(cc)(1)The term comprehensive outpatient rehabilitation facility services means the following items and services furnished by a physicianor other qualified professional personnel (as defined in regulationsby the Secretary) to an individual who is an outpatient of a comprehensiveoutpatient rehabilitation facility under a plan (for furnishing suchitems and services to such individual) established and periodicallyreviewed by a physician(A)physiciansservices;(B)physicaltherapy, occupational therapy, speech-language pathology services,and respiratory therapy;(C)prostheticand orthotic devices, including testing, fitting, or training in theuse of prosthetic and orthotic devices;(D)social andpsychological services;(E)nursingcare provided by or under the supervision of a registered professionalnurse;(F)drugs andbiologicals which cannot, as determined in accordance with regulations,be self-administered;(G)suppliesand durable medical equipment; and(H)such otheritems and services as are medically necessary for the rehabilitationof the patient and are ordinarily furnished by comprehensive outpatientrehabilitation facilities,excluding, however, any item or service if it would not be includedunder subsection (b) if furnished to an inpatient of a hospital. Inthe case of physical therapy, occupational therapy, and speech pathologyservices, there shall be no requirement that the item or service befurnished at any single fixed location if the item or service is furnishedpursuant to such plan and payments are not otherwise made for theitem or service under this title.(2)The term comprehensive outpatient rehabilitation facility means afacility which(A)is primarilyengaged in providing (by or under the supervision of physicians) diagnostic,therapeutic, and restorative services to outpatients for the rehabilitationof injured, disabled, or sick persons;
Social Security Act §1861
(A)is primarilyengaged in providing (by or under the supervision of physicians) diagnostic,therapeutic, and restorative services to outpatients for the rehabilitationof injured, disabled, or sick persons;(B)providesat least the following comprehensive outpatient rehabilitation services:(i) physicians services (rendered by physicians, as definedin section 1861(r)(1), who are available at the facility on a full-or part-time basis);(ii) physical therapy; and (iii) social or psychological services;(C)maintainsclinical records on all patients;(D)has policiesestablished by a group of professional personnel (associated withthe facility), including one or more physicians defined in subsection(r)(1) to govern the comprehensive outpatient rehabilitation servicesit furnishes, and provides for the carrying out of such policies bya full-or part-time physician referred to in subparagraph (B)(i);(E)has a requirementthat every patient must be under the care of a physician;(F)in the caseof a facility in any State in which State or applicable local lawprovides for the licensing of facilities of this nature (i) is licensedpursuant to such law, or (ii) is approved by the agency of such Stateor locality, responsible for licensing facilities of this nature,as meeting the standards established for such licensing;(G)has in effecta utilization review plan in accordance with regulations prescribedby the Secretary;(H)has in effectan overall plan and budget that meets the requirements of subsection(z);(I)providesthe Secretary on a continuing basis with a surety bond in a form specifiedby the Secretary and in an amount that is not less than $50,000; and(J)meets suchother conditions of participation as the Secretary may find necessaryin the interest of the health and safety of individuals who are furnishedservices by such facility, including conditions concerning qualificationsof personnel in these facilities.Hospice Care; Hospice Program(dd)(1)Theterm hospice care means the following items and servicesprovided to a terminally ill individual by, or by others under arrangementsmade by, a hospice program under a written plan (for providing suchcare to such individual) established and periodically reviewed bythe individuals attending physician and by the medical director(and by the interdisciplinary group described in paragraph (2)(B))of the program