42 C.F.R. PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
Subpart A--INTRODUCTION AND GENERAL RULES
|
|
| Cost reimbursement: General.
|
|
|
|
| Cost related to patient care.
|
|
|
|
| Amount of payment if customary charges for services furnished are less than reasonable costs.
|
|
|
|
| Cost to related organizations.
|
|
Subpart B--ACCOUNTING RECORDS AND REPORTS
|
|
| Financial data and reports.
|
|
|
|
| Adequate cost data and cost finding.
|
|
Subpart C--LIMITS ON COST REIMBURSEMENT
|
|
| Limitations on payable costs.
|
|
|
|
| Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.
|
|
|
|
| Ceiling on the rate of increase in hospital inpatient costs.
|
|
Subpart D--APPORTIONMENT
|
|
| Apportionment of allowable costs.
|
|
|
|
| Determination of cost of services to beneficiaries.
|
|
Subpart E--PAYMENTS TO PROVIDERS
|
|
| Payments to providers: General.
|
|
|
|
| Payments to providers: Specific rules.
|
|
|
|
| Requirements for a determination that a facility or an organization has provider-based status.
|
|
|
|
| Payment for services of a CAH.
|
|
|
|
| Payment to a foreign hospital.
|
|
Subpart F--SPECIFIC CATEGORIES OF COSTS
|
|
| Direct GME payments: General requirements.
|
|
|
|
| Direct GME payments: Calculation of payments for GME costs.
|
|
|
|
| Direct GME payments: Determination of per resident amounts.
|
|
|
|
| Direct GME payments: Determination of the total number of FTE residents.
|
|
|
|
| Direct GME payments: Determination of the weighted number of FTE residents.
|
|
|
|
| Direct GME payments: Determination of weighting factors for foreign medical graduates.
|
|
|
|
| Direct GME payments: Application of community support and redistribution of costs in determining FTE resident counts.
|
|
|
|
| Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement principles.
|
|
|
|
| Direct GME payments: Adjustment of a hospital's target amount or prospective payment hospital-specific rate.
|
|
|
|
| Cost of approved nursing and allied health education activities.
|
|
|
|
| Payments for Medicare+Choice nursing and allied health education programs.
|
|
|
|
| Incentive payments under plans for voluntary reduction in number of medical residents.
|
|
|
|
| Bad debts, charity, and courtesy allowances.
|
|
|
|
| Value of services of nonpaid workers.
|
|
|
|
| Purchase discounts and allowances, and refunds of expenses.
|
|
|
|
| Special treatment of certain accrued costs.
|
|
|
|
| Reasonable cost of physical and other therapy services furnished under arrangements.
|
|
|
|
| Payment for posthospital SNF care furnished by a swing-bed hospital.
|
|
|
|
| Payment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.
|
|
|
|
| Payment for hospital outpatient radiology services and other diagnostic procedures.
|
|
|
|
| Payment for screening mammography performed by hospitals on an outpatient basis.
|
|
|
|
| Reduction to hospital outpatient operating costs.
|
|
|
|
| Payment for home health agency services.
|
|
Subpart G--CAPITAL-RELATED COSTS
|
|
| Introduction to capital-related costs.
|
|
|
|
| Depreciation: Allowance for depreciation based on asset costs.
|
|
|
|
| Depreciation: Optional allowance for depreciation based on a percentage of operating costs.
|
|
|
|
| Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.
|
|
|
|
| Depreciation: Allowance for depreciation on assets financed with Federal or public funds.
|
|
|
|
| Return on equity capital of proprietary providers.
|
|
Subpart H--PAYMENT FOR END-STAGE RENAL DISEASE (ESRD) SERVICES AND ORGAN PROCUREMENT COSTS
|
|
| Principles of prospective payment.
|
|
|
|
| Prospective rates for hospital-based and independent ESRD facilities.
|
|
|
|
| Procedures for requesting exceptions to payment rates.
|
|
|
|
| Criteria for approval of exception requests.
|
|
|
|
| Payment exception: Atypical service intensity (patient mix).
|
|
|
|
| Payment exception: Self-dialysis training costs in pediatric facilities.
|
|
|
|
| Notification of changes in rate-setting methodologies and payment rates.
|
|
|
|
| Recordkeeping and cost reporting requirements for outpatient maintenance dialysis.
|
|
|
|
| Payment of independent organ procurement organizations and histocompatibility laboratories.
|
|
|
|
| Organ procurement organization (OPO) cost for kidneys sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
|
|
|
|
| Transplant center costs for organs sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
|
|
Subpart I--PROSPECTIVELY DETERMINED PAYMENT RATES FOR LOW-VOLUME SKILLED NURSING FACILITIES, FOR COST REPORTING PERIODS BEGINNING PRIOR TO JULY 1, 1998
|
|
| Eligibility for prospectively determined payment rates.
|
|
|
|
| Rules governing election of prospectively determined payment rates.
|
|
|
|
| Methodology for calculating rates.
|
|
|
|
| Determining payment amounts: Routine per diem rate.
|
|
|
|
| Determining payment amounts: Ancillary services.
|
|
|
|
| Publication of prospectively determined payment rates or amounts.
|
|
|
|
| Simplified cost report for SNFs.
|
|
Subpart J--PROSPECTIVE PAYMENT FOR SKILLED NURSING FACILITIES
|
|
| Methodology for calculating the prospective payment rates.
|
|
|
|
| Resident assessment data.
|
|
|
|
| Publication of Federal prospective payment rates.
|
|
|
|
| Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A services.
|
|
|
|
| Additional payment: QIO photocopy and mailing costs.
|
|
