Title 42

PART 413

Part 413 - Principles Of Reasonable Cost Reimbursement; Payment For End-stage Renal Disease Services; Prospectively Determined Payment Rates For Skilled Nursing Facilities; Payment For Acute Kidney Injury Dialysis

PART 413 - PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES; PAYMENT FOR ACUTE KIDNEY INJURY DIALYSIS Authority:42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww. Source:51 FR 34793, Sept. 30, 1986, unless otherwise noted. Editorial Note:Nomenclature changes to part 413 appear at 76 FR 50537, August 22, 2014.

42:2.0.1.2.13.1SUBPART A
Subpart A - Introduction and General Rules
42:2.0.1.2.13.1.59.1SECTION 413.1
   413.1 Introduction.
42:2.0.1.2.13.1.59.2SECTION 413.5
   413.5 Cost reimbursement: General.
42:2.0.1.2.13.1.59.3SECTION 413.9
   413.9 Cost related to patient care.
42:2.0.1.2.13.1.59.4SECTION 413.13
   413.13 Amount of payment if customary charges for services furnished are less than reasonable costs.
42:2.0.1.2.13.1.59.5SECTION 413.17
   413.17 Cost to related organizations.
42:2.0.1.2.13.2SUBPART B
Subpart B - Accounting Records and Reports
42:2.0.1.2.13.2.59.1SECTION 413.20
   413.20 Financial data and reports.
42:2.0.1.2.13.2.59.2SECTION 413.24
   413.24 Adequate cost data and cost finding.
42:2.0.1.2.13.3SUBPART C
Subpart C - Limits on Cost Reimbursement
42:2.0.1.2.13.3.59.1SECTION 413.30
   413.30 Limitations on payable costs.
42:2.0.1.2.13.3.59.2SECTION 413.35
   413.35 Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.
42:2.0.1.2.13.3.59.3SECTION 413.40
   413.40 Ceiling on the rate of increase in hospital inpatient costs.
42:2.0.1.2.13.4SUBPART D
Subpart D - Apportionment
42:2.0.1.2.13.4.59.1SECTION 413.50
   413.50 Apportionment of allowable costs.
42:2.0.1.2.13.4.59.2SECTION 413.53
   413.53 Determination of cost of services to beneficiaries.
42:2.0.1.2.13.4.59.3SECTION 413.56
   413.56 [Reserved]
42:2.0.1.2.13.5SUBPART E
Subpart E - Payments to Providers
42:2.0.1.2.13.5.59.1SECTION 413.60
   413.60 Payments to providers: General.
42:2.0.1.2.13.5.59.2SECTION 413.64
   413.64 Payments to providers: Specific rules.
42:2.0.1.2.13.5.59.3SECTION 413.65
   413.65 Requirements for a determination that a facility or an organization has provider-based status.
42:2.0.1.2.13.5.59.4SECTION 413.70
   413.70 Payment for services of a CAH.
42:2.0.1.2.13.5.59.5SECTION 413.74
   413.74 Payment to a foreign hospital.
42:2.0.1.2.13.6SUBPART F
Subpart F - Specific Categories of Costs
42:2.0.1.2.13.6.59.1SECTION 413.75
   413.75 Direct GME payments: General requirements.
42:2.0.1.2.13.6.59.2SECTION 413.76
   413.76 Direct GME payments: Calculation of payments for GME costs.
42:2.0.1.2.13.6.59.3SECTION 413.77
   413.77 Direct GME payments: Determination of per resident amounts.
42:2.0.1.2.13.6.59.4SECTION 413.78
   413.78 Direct GME payments: Determination of the total number of FTE residents.
42:2.0.1.2.13.6.59.5SECTION 413.79
   413.79 Direct GME payments: Determination of the weighted number of FTE residents.
42:2.0.1.2.13.6.59.6SECTION 413.80
   413.80 Direct GME payments: Determination of weighting factors for foreign medical graduates.
42:2.0.1.2.13.6.59.7SECTION 413.81
   413.81 Direct GME payments: Application of community support and redistribution of costs in determining FTE resident counts.
42:2.0.1.2.13.6.59.8SECTION 413.82
   413.82 Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement principles.
42:2.0.1.2.13.6.59.9SECTION 413.83
   413.83 Direct GME payments: Adjustment of a hospital's target amount or prospective payment hospital-specific rate.
42:2.0.1.2.13.6.59.10SECTION 413.85
   413.85 Cost of approved nursing and allied health education activities.
42:2.0.1.2.13.6.59.11SECTION 413.87
   413.87 Payments for Medicare + Choice nursing and allied health education programs.
42:2.0.1.2.13.6.59.12SECTION 413.88
   413.88 Incentive payments under plans for voluntary reduction in number of medical residents.
42:2.0.1.2.13.6.59.13SECTION 413.89
   413.89 Bad debts, charity, and courtesy allowances.
42:2.0.1.2.13.6.59.14SECTION 413.90
   413.90 Research costs.
42:2.0.1.2.13.6.59.15SECTION 413.92
   413.92 Costs of surety bonds.
42:2.0.1.2.13.6.59.16SECTION 413.94
   413.94 Value of services of nonpaid workers.
42:2.0.1.2.13.6.59.17SECTION 413.98
   413.98 Purchase discounts and allowances, and refunds of expenses.
42:2.0.1.2.13.6.59.18SECTION 413.100
   413.100 Special treatment of certain accrued costs.
42:2.0.1.2.13.6.59.19SECTION 413.102
   413.102 Compensation of owners.
42:2.0.1.2.13.6.59.20SECTION 413.106
   413.106 Reasonable cost of physical and other therapy services furnished under arrangements.
42:2.0.1.2.13.6.59.21SECTION 413.114
   413.114 Payment for posthospital SNF care furnished by a swing-bed hospital.
42:2.0.1.2.13.6.59.22SECTION 413.118
   413.118 Payment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.
42:2.0.1.2.13.6.59.23SECTION 413.122
   413.122 Payment for hospital outpatient radiology services and other diagnostic procedures.
42:2.0.1.2.13.6.59.24SECTION 413.123
   413.123 Payment for screening mammography performed by hospitals on an outpatient basis.
42:2.0.1.2.13.6.59.25SECTION 413.124
   413.124 Reduction to hospital outpatient operating costs.
42:2.0.1.2.13.6.59.26SECTION 413.125
   413.125 Payment for home health agency services.
42:2.0.1.2.13.7SUBPART G
Subpart G - Capital-Related Costs
42:2.0.1.2.13.7.59.1SECTION 413.130
   413.130 Introduction to capital-related costs.
42:2.0.1.2.13.7.59.2SECTION 413.134
   413.134 Depreciation: Allowance for depreciation based on asset costs.
42:2.0.1.2.13.7.59.3SECTION 413.139
   413.139 Depreciation: Optional allowance for depreciation based on a percentage of operating costs.
42:2.0.1.2.13.7.59.4SECTION 413.144
   413.144 Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.
42:2.0.1.2.13.7.59.5SECTION 413.149
   413.149 Depreciation: Allowance for depreciation on assets financed with Federal or public funds.
42:2.0.1.2.13.7.59.6SECTION 413.153
   413.153 Interest expense.
42:2.0.1.2.13.7.59.7SECTION 413.157
   413.157 Return on equity capital of proprietary providers.
42:2.0.1.2.13.8SUBPART H
Subpart H - Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs
42:2.0.1.2.13.8.59.1SECTION 413.170
   413.170 Scope.
42:2.0.1.2.13.8.59.2SECTION 413.171
   413.171 Definitions.
42:2.0.1.2.13.8.59.3SECTION 413.172
   413.172 Principles of prospective payment.
42:2.0.1.2.13.8.59.4SECTION 413.174
   413.174 Prospective rates for hospital-based and independent ESRD facilities.
42:2.0.1.2.13.8.59.5SECTION 413.176
   413.176 Amount of payments.
42:2.0.1.2.13.8.59.6SECTION 413.177
   413.177 Quality incentive program payment.
42:2.0.1.2.13.8.59.7SECTION 413.178
   413.178 ESRD quality incentive program.
42:2.0.1.2.13.8.59.8SECTION 413.180
   413.180 Procedures for requesting exceptions to payment rates.
42:2.0.1.2.13.8.59.9SECTION 413.182
   413.182 Criteria for approval of exception requests.
42:2.0.1.2.13.8.59.10SECTION 413.184
   413.184 Payment exception: Pediatric patient mix.
42:2.0.1.2.13.8.59.11SECTION 413.186
   413.186 Payment exception: Self-dialysis training costs in pediatric facilities.
42:2.0.1.2.13.8.59.12SECTION 413.194
   413.194 Appeals.
42:2.0.1.2.13.8.59.13SECTION 413.195
   413.195 Limitation on Review.
42:2.0.1.2.13.8.59.14SECTION 413.196
   413.196 Notification of changes in rate-setting methodologies and payment rates.
42:2.0.1.2.13.8.59.15SECTION 413.198
   413.198 Recordkeeping and cost reporting requirements for outpatient maintenance dialysis.
42:2.0.1.2.13.8.59.16SECTION 413.200
   413.200 Payment of independent organ procurement organizations and histocompatibility laboratories.
42:2.0.1.2.13.8.59.17SECTION 413.202
   413.202 Organ procurement organization (OPO) cost for kidneys sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.13.8.59.18SECTION 413.203
   413.203 Transplant center costs for organs sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.13.8.59.19SECTION 413.210
   413.210 Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.
42:2.0.1.2.13.8.59.20SECTION 413.215
   413.215 Basis of payment.
42:2.0.1.2.13.8.59.21SECTION 413.217
   413.217 Items and services included in the ESRD prospective payment system.
42:2.0.1.2.13.8.59.22SECTION 413.220
   413.220 Methodology for calculating the per-treatment base rate under the ESRD prospective payment system effective January 1, 2011.
42:2.0.1.2.13.8.59.23SECTION 413.230
   413.230 Determining the per treatment payment amount.
42:2.0.1.2.13.8.59.24SECTION 413.231
   413.231 Adjustment for wages.
42:2.0.1.2.13.8.59.25SECTION 413.232
   413.232 Low-volume adjustment.
42:2.0.1.2.13.8.59.26SECTION 413.233
   413.233 Rural facility adjustment.
42:2.0.1.2.13.8.59.27SECTION 413.234.
   413.234. Drug designation process.
42:2.0.1.2.13.8.59.28SECTION 413.235
   413.235 Patient-level adjustments.
42:2.0.1.2.13.8.59.29SECTION 413.236
   413.236 Transitional add-on payment adjustment for new and innovative equipment and supplies.
42:2.0.1.2.13.8.59.30SECTION 413.237
   413.237 Outliers.
42:2.0.1.2.13.8.59.31SECTION 413.239
   413.239 Transition period.
42:2.0.1.2.13.8.59.32SECTION 413.241
   413.241 Pharmacy arrangements.
42:2.0.1.2.13.9SUBPART I
Subpart I - Prospectively Determined Payment Rates for Low-Volume Skilled Nursing Facilities, for Cost Reporting Periods Beginning Prior to July 1, 1998
42:2.0.1.2.13.9.59.1SECTION 413.300
   413.300 Basis and scope.
42:2.0.1.2.13.9.59.2SECTION 413.302
   413.302 Definitions.
42:2.0.1.2.13.9.59.3SECTION 413.304
   413.304 Eligibility for prospectively determined payment rates.
42:2.0.1.2.13.9.59.4SECTION 413.308
   413.308 Rules governing election of prospectively determined payment rates.
42:2.0.1.2.13.9.59.5SECTION 413.310
   413.310 Basis of payment.
42:2.0.1.2.13.9.59.6SECTION 413.312
   413.312 Methodology for calculating rates.
42:2.0.1.2.13.9.59.7SECTION 413.314
   413.314 Determining payment amounts: Routine per diem rate.
42:2.0.1.2.13.9.59.8SECTION 413.316
   413.316 Determining payment amounts: Ancillary services.
42:2.0.1.2.13.9.59.9SECTION 413.320
   413.320 Publication of prospectively determined payment rates or amounts.
42:2.0.1.2.13.9.59.10SECTION 413.321
   413.321 Simplified cost report for SNFs.
42:2.0.1.2.13.10SUBPART J
Subpart J - Prospective Payment for Skilled Nursing Facilities
42:2.0.1.2.13.10.59.1SECTION 413.330
   413.330 Basis and scope.
42:2.0.1.2.13.10.59.2SECTION 413.333
   413.333 Definitions.
42:2.0.1.2.13.10.59.3SECTION 413.335
   413.335 Basis of payment.
42:2.0.1.2.13.10.59.4SECTION 413.337
   413.337 Methodology for calculating the prospective payment rates.
42:2.0.1.2.13.10.59.5SECTION 413.338
   413.338 Skilled nursing facility value-based purchasing program.
42:2.0.1.2.13.10.59.6SECTION 413.340
   413.340 Transition period.
42:2.0.1.2.13.10.59.7SECTION 413.343
   413.343 Resident assessment data.
42:2.0.1.2.13.10.59.8SECTION 413.345
   413.345 Publication of Federal prospective payment rates.
42:2.0.1.2.13.10.59.9SECTION 413.348
   413.348 Limitation on review.
42:2.0.1.2.13.10.59.10SECTION 413.350
   413.350 Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A services.
42:2.0.1.2.13.10.59.11SECTION 413.355
   413.355 Additional payment: QIO photocopy and mailing costs.
42:2.0.1.2.13.10.59.12SECTION 413.360
   413.360 Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
42:2.0.1.2.13.11SUBPART K
Subpart K - Payment for Acute Kidney Injury (AKI) Dialysis
42:2.0.1.2.13.11.59.1SECTION 413.370
   413.370 Scope.
42:2.0.1.2.13.11.59.2SECTION 413.371
   413.371 Definition.
42:2.0.1.2.13.11.59.3SECTION 413.372
   413.372 AKI dialysis payment rate.
42:2.0.1.2.13.11.59.4SECTION 413.373
   413.373 Other adjustments to the AKI dialysis payment rate
42:2.0.1.2.13.11.59.5SECTION 413.374
   413.374 Renal dialysis services included in the AKI dialysis payment rate
42:2.0.1.2.13.11.59.6SECTION 413.375
   413.375 Notification of changes in rate-setting methodologies and payment rates.