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 him 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 he will remain at least over night and occupy
a bed even though it later develops that he can be discharged and does 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
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.)