[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2006]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.133]

[Page 265]
 
                         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 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]