[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR412.20]



[Page 462]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 412_PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

--Table of Contents

 

Subpart B_Hospital Services Subject to and Excluded From the Prospective 

  Payment Systems for Inpatient Operating Costs and Inpatient Capital-

                              Related Costs

 

Sec. 412.20  Hospital services subject to the prospective payment systems.





    (a) Except for services described in paragraphs (b), (c), (d), and 

(e) of this section, all covered hospital inpatient services furnished 

to beneficiaries during the subject cost reporting periods are paid 

under the prospective payment system as specified in Sec. 412.1(a)(1).

    (b) Effective for cost reporting periods beginning on or after 

January 1, 2005, covered inpatient hospital services furnished to 

Medicare beneficiaries by a inpatient psychiatric facility that meets 

the conditions of Sec. 412.404 are paid under the prospective payment 

system described in subpart N of this part.

    (c)(1) Effective for cost reporting periods beginning on or after 

January 1, 2002, covered inpatient hospital services furnished to 

Medicare beneficiaries by a rehabilitation hospital or rehabilitation 

unit that meet the conditions of Sec. 412.604 are paid under the 

prospective payment system described in subpart P of this part.

    (2) CMS will not pay for services under Subpart P of this part if 

the services are paid for by a health maintenance organization (HMO) or 

competitive medical plan (CMP) that elects not to have CMS make payments 

to an inpatient rehabilitation facility for services, which are 

inpatient hospital services, furnished to the HMO's or CMP's Medicare 

enrollees, as provided under part 417 of this chapter.

    (d) Effective for cost reporting periods beginning on or after 

October 1, 2002, covered inpatient hospital services furnished to 

Medicare beneficiaries by a long-term care hospital that meets the 

conditions for payment of Sec. Sec. 412.505 through 412.511 are paid 

under the prospective payment system described in subpart O of this 

part.

    (e) Inpatient hospital services will not be paid under the 

prospective payment systems specified in Sec. 412.1(a)(1) under any of 

the following circumstances:

    (1) The services are furnished by a hospital (or hospital unit) 

explicitly excluded from the prospective payment systems under 

Sec. Sec. 412.23, 412.25, 412.27, and 412.29.

    (2) The services are emergency services furnished by a 

nonparticipating hospital in accordance with Sec. 424.103 of this 

chapter.

    (3) The services are paid for by an HMO or competitive medical plan 

(CMP) that elects not to have CMS make payments directly to a hospital 

for inpatient hospital services furnished to the HMO's or CMP's Medicare 

enrollees, as provided in Sec. 417.240(d) and Sec. 417.586 of this 

chapter.



[50 FR 12741, Mar. 29, 1985, as amended at 53 FR 6648, Mar. 2, 1988; 57 

FR 39820, Sept. 1, 1992; 59 FR 45400, Sept. 1, 1994; 66 FR 41386, Aug. 

7, 2001; 67 FR 56048, Aug. 30, 2002; 68 FR 45698, Aug. 1, 2003; 69 FR 

66976, Nov. 15, 2004]