[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: 42CFR422.133]



[Page 1005-1006]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart C_Benefits and Beneficiary Protections

 

Sec. 422.133  Return to home skilled nursing facility.



    (a) General rule. MA plans must provide coverage of posthospital 

extended care services to Medicare enrollees through a home skilled 

nursing facility if the enrollee elects to receive the coverage through 

the home skilled nursing facility, and if the home skilled nursing 

facility either has a contract with the MA organization or agrees to 

accept substantially similar payment under the same terms and conditions 

that apply to similar skilled nursing facilities that contract with the 

MA organization.

    (b) Definitions. In this subpart, home skilled nursing facility 

means--

    (1) The skilled nursing facility in which the enrollee resided at 

the time of admission to the hospital preceding the receipt of 

posthospital extended care services;

    (2) A skilled nursing facility that is providing posthospital 

extended care services through a continuing care retirement community in 

which the MA plan enrollee was a resident at the time of admission to 

the hospital. A continuing care retirement community is an arrangement 

under which housing and health-related services are provided (or 

arranged) through an organization for the enrollee under an agreement 

that is effective for the life of the enrollee or for a specified 

period; or

    (3) The skilled nursing facility in which the spouse of the enrollee 

is residing at the time of discharge from the hospital.

    (4) If an MA organization elects to furnish SNF care in the absence 

of a prior qualifying hospital stay under Sec. 422.101(c), then that 

SNF care is also subject to the home skilled nursing facility rules in 

this section. In applying the provisions of this section to coverage 

under this paragraph, references to a hospitalization, or discharge from 

a hospital, are deemed to refer to wherever the enrollee resides 

immediately before admission for extended care services.

    (c) Coverage no less favorable. The posthospital extended care scope 

of services, cost-sharing, and access to coverage provided by the home 

skilled nursing facility must be no less favorable to the enrollee than 

posthospital extended care services coverage that would be provided to 

the enrollee by a skilled nursing facility that would be otherwise 

covered under the MA plan.

    (d) Exceptions. The requirement to allow an MA plan enrollee to 

elect to return to the home skilled nursing facility for posthospital 

extended care services after discharge from the hospital does not do the 

following:

    (1) Require coverage through a skilled nursing facility that is not 

otherwise qualified to provide benefits under Part A for Medicare 

beneficiaries not enrolled in the MA plan.

    (2) Prevent a skilled nursing facility from refusing to accept, or 

imposing



[[Page 1006]]



conditions on the acceptance of, an enrollee for the receipt of 

posthospital extended care services.



[68 FR 50857, Aug. 22, 2003, as amended at 70 FR 4723, Jan. 28, 2005]