A. General

An individual who meets the requirements for entitlement contained in HI 00801.001 and receives inpatient hospital services in a participating hospital shall be entitled to coverage if (1) the services are not excluded from coverage for any of the circumstances listed in HI 00620.000 and (2) the individual meets the hospital level of care requirements.

Emergency services in a nonparticipating hospital may be covered.

Hospital inpatient services covered by the Medicare program represent a discrete level of care. Two criteria must be satisfied in order for the hospital level of care requirement to be met: the services the patient receives in the hospital must be medically indicated; and it must be reasonable to provide the needed care in a hospital rather than in a less costly facility or on an outpatient basis. In determining whether these criteria are met, consideration is given to factors such as the patient's condition and their need for the kinds of physician supervision, around-the-clock nursing or the facilities available only in hospitals.