A private room is medically necessary when isolation of a beneficiary is required to avoid jeopardizing their health or recovery, or that of other patients who are likely to be alarmed or disturbed by the beneficiary’s communicable disease. For example, communicable disease, heart attacks, cerebrovascular accidents, and psychotic episodes may require isolation of the patient for certain periods.

In establishing the medical necessity for isolation, the date of the physician’s written statement is not controlling, nor is the presence of a written statement. The crucial question is whether a private room was ordered by the physician because it was necessary for the health of the patient themself or that of other patients.

A private room is considered to be medically necessary even though the beneficiary’s condition does not require isolation if they need immediate hospitalization (i.e., their medical condition is such that hospitalization cannot be deferred) and the hospital has no semiprivate or ward accommodations available at the time of admission. Such beneficiary may not be charged for the private room while the other accommodations remain unavailable.

If the patient is admitted to a provider which has only private accommodations, and no semiprivate or ward accommodations, medical necessity will be deemed to exist for the accommodations furnished. Beneficiaries are not to be subject to an extra charge for a private room in an all-private room provider.

A beneficiary who needs a private room may be assigned to any of the provider’s private rooms.

Although they do not have the right to insist on the private room of their choice, their preferences are given the same consideration as if they were paying all provider charges themselves. The program does not, under any circumstances, pay for personal comfort items. Thus, the program does not pay for deluxe accommodations and/or services; these include a suite, or a room substantially more spacious than is required for treatment, or specially equipped or decorated, or serviced for the comfort and convenience of persons willing to pay a differential for such amenities. If they (or their representative) requests such deluxe accommodations, the provider advises them that there will be a charge, not covered by Medicare, of a specified amount per day and may charge them that amount for each day they occupy the deluxe accommodations.

The beneficiary may not be charged such a differential in private room rates if that differential is based on factors other than personal comfort items. Such factors might include differences between older and newer wings, proximity to lounge, elevators or nursing stations, desirable view, etc. Such rooms are standard one-bed units and not deluxe room for purposes for these instructions, even though the provider may call them deluxe and have a higher customary charge for them. No additional charge may be imposed upon the beneficiary who is assigned to a room which may be somewhat more desirable because of these factors.

It is consistent with program purposes to assign the patient to ward accommodations if all semiprivate accommodations are occupied, or the facility has no semiprivate accommodations. However, the patient must be moved to semiprivate accommodations if they become available during their stay.

Some providers have a policy of placing in wards all patients who do not have private physicians. Such a practice may be consistent with the purposes of the program if the intermediary determines that the ward assignment insures to the benefit of the patient. In making this determination, the intermediary’s principal consideration is whether the assignment is likely to result in better medical treatment of the patient (e.g., it facilitates necessary medical and nursing supervision and treatment).

It is not consistent with the purposes of the law to assign a patient ward accommodations on the basis of their social or economic status, their national origin, race, or religion, or their entitlement to benefits as a Medicare patient, or any other such discriminatory reason. It is also inconsistent with the purposes of the law to assign patients to ward accommodations merely for the convenience or financial advantage of the institution.

If a ward assignment is made neither at the patient’s request nor for a reason consistent with the purpose of the program, the reimbursement to the provider for the routine services is decreased. The reduction in payment, when applicable, is made by the intermediary at the end-of-year settlement.