A. General
Effective for accounting periods beginning after December 31, 1971, CMS regulations provide for apportionment of routine service costs on the basis of average per diem cost under both the Departmental and the Combination methods of cost apportionment. Thus, the program will pay the same amount for routine services whether the patient has a private room not medically necessary, a private room medically necessary (Medicare does not pay for deluxe accommodations in any case), a semiprivate room (two, three, or four-bed accommodations), or ward accommodations, if its ward accommodations are consistent with program purposes (see C. below).
A provider having both private and semiprivate accommodations may nevertheless charge the patient a differential for a private room if:
1. The private room is not medically necessary; and
2. The patient (or relative or other person acting on their behalf) has requested the private room and the provider informs them at the time of the request of the amount of the charge.
The private room differential may not exceed the difference between the customary charge for the accommodations furnished and the most prevalent semiprivate accommodation rate at the time of the patient’s admission.
When the provider bills for a private room as a covered service, the intermediary deems the private room to have been medically necessary. When the provider shows a private room differential as a non-covered charge, the intermediary assumes that the private room was not medically necessary.
If the beneficiary (or their representative) protests a charge for the private room on the grounds that the privacy was medically necessary, or that the provider did not inform them of the charge, assist them in filing a reconsideration and forward it to the intermediary. The intermediary will develop the facts and make a specific determination regarding the medical necessity of the private room.
When it is necessary to develop the medical necessity of a private room, the guidelines in subsection B. apply.