HI 00601.175 Covered Extended Care Services

Patients covered under hospital insurance are entitled to have payment made on their behalf on a reasonable cost basis for covered extended care services. If a patient receives items or services in excess of, or more expensive than, those for which payment can be made, payment will be made only for the reasonable cost of the covered items or services. If the items or services are requested by the patient, the facility may charge them the difference between the amount customarily charged for the services requested and the amount customarily charged for covered services.

An inpatient is a person who has been admitted to an SNF for bed occupancy for purposes of receiving inpatient services. A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least over night and occupy a bed even though it later develops that they can be discharged and do not actually use a bed over night.

NOTE: 1. Custodial care (see HI 00620.130 ) is not a covered extended care service.

NOTE: 2. When patients requiring inpatient hospital services occupy beds in an SNF, they are considered inpatients of the SNF. In such cases, the services furnished in the SNF may not be considered inpatient hospital services, and payment may not be made under the program. Such a situation may arise when the SNF is a distinct part of an institution, the remainder of which is a hospital, and either there is no bed available or for any other reason the institution fails to place the patient in the appropriate bed. The same rule applies where the skilled nursing facility is a separate institution. For the same reason, where patients who require extended care services occupy beds in a hospital, payment cannot be made for the services furnished to them in the hospital.

NOTE: 3. When patients who require SNF services are placed in a noncertified part of an institution which contains a participating “distinct part” SNF, the services may be paid under certain conditions, based on the waiver of liability provisions.

NOTE: 4. The application of the responsible and necessary payment exclusion to diagnostic procedures such as chest X-rays, urinalysis, etc provided to patients upon admission to a hospital also applies when such services are provided to patients upon admission to a skilled nursing facility. (See HI 00601.010 E. )