Title 42, 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

123 sections

Section 413.1

Introduction.

Section 413.5

Cost reimbursement: General.

Section 413.9

Cost related to patient care.

Section 413.13

Amount of payment if customary charges for services furnished are less than reasonable costs.

Section 413.17

Cost to related organizations.

Section 413.20

Financial data and reports.

Section 413.24

Adequate cost data and cost finding.

Section 413.30

Limitations on payable costs.

Section 413.35

Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.

Section 413.40

Ceiling on the rate of increase in hospital inpatient costs.

Section 413.50

Apportionment of allowable costs.

Section 413.53

Determination of cost of services to beneficiaries.

Section 413.56

[Reserved]

Section 413.60

Payments to providers: General.

Section 413.64

Payments to providers: Specific rules.

Section 413.65

Requirements for a determination that a facility or an organization has provider-based status.

Section 413.70

Payment for services of a CAH.

Section 413.74

Payment to a foreign hospital.

Section 413.75

Direct GME payments: General requirements.

Section 413.76

Direct GME payments: Calculation of payments for GME costs.

Section 413.77

Direct GME payments: Determination of per resident amounts.

Section 413.78

Direct GME payments: Determination of the total number of FTE residents.

Section 413.79

Direct GME payments: Determination of the weighted number of FTE residents.

Section 413.80

Direct GME payments: Determination of weighting factors for foreign medical graduates.

Section 413.81

Direct GME payments: Application of community support and redistribution of costs in determining FTE resident counts.

Section 413.82

Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement principles.

Section 413.83

Direct GME payments: Adjustment of a hospital's target amount or prospective payment hospital-specific rate.

Section 413.85

Cost of approved nursing and allied health education activities.

Section 413.87

Payments for Medicare + Choice nursing and allied health education programs.

Section 413.88

Incentive payments under plans for voluntary reduction in number of medical residents.

Section 413.89

Bad debts, charity, and courtesy allowances.

Section 413.90

Research costs.

Section 413.92

Costs of surety bonds.

Section 413.94

Value of services of nonpaid workers.

Section 413.98

Purchase discounts and allowances, and refunds of expenses.

Section 413.99

Qualified and Non-Qualified Deferred Compensation Plans.

Section 413.100

Special treatment of certain accrued costs.

Section 413.102

Compensation of owners.

Section 413.106

Reasonable cost of physical and other therapy services furnished under arrangements.

Section 413.114

Payment for posthospital SNF care furnished by a swing-bed hospital.

Section 413.118

Payment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.

Section 413.122

Payment for hospital outpatient radiology services and other diagnostic procedures.

Section 413.123

Payment for screening mammography performed by hospitals on an outpatient basis.

Section 413.124

Reduction to hospital outpatient operating costs.

Section 413.125

Payment for home health agency services.

Section 413.130

Introduction to capital-related costs.

Section 413.134

Depreciation: Allowance for depreciation based on asset costs.

Section 413.139

Depreciation: Optional allowance for depreciation based on a percentage of operating costs.

Section 413.144

Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.

Section 413.149

Depreciation: Allowance for depreciation on assets financed with Federal or public funds.

Section 413.153

Interest expense.

Section 413.157

Return on equity capital of proprietary providers.

Principles of prospective payment.

Section 413.174

Prospective rates for hospital-based and independent ESRD facilities.

Section 413.176

Amount of payments.

Section 413.177

Quality incentive program payment.

Section 413.178

ESRD quality incentive program.

Section 413.180

Procedures for requesting exceptions to payment rates.

Section 413.182

Criteria for approval of exception requests.

Section 413.184

Payment exception: Pediatric patient mix.

Section 413.186

Payment exception: Self-dialysis training costs in pediatric facilities.

Section 413.194

Appeals.

Section 413.195

Limitation on Review.

Section 413.196

Notification of changes in rate-setting methodologies and payment rates.

Section 413.198

Recordkeeping and cost reporting requirements for outpatient maintenance dialysis.

Section 413.200

[Reserved]

Section 413.202

Organ procurement organization (OPO) cost for kidneys sent to foreign countries or transplanted in patients other than Medicare beneficiaries.

Section 413.203

Transplant center costs for organs sent to foreign countries or transplanted in patients other than Medicare beneficiaries.

Section 413.210

Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Section 413.215

Basis of payment.

Section 413.217

Items and services included in the ESRD prospective payment system.

Section 413.220

Methodology for calculating the per-treatment base rate under the ESRD prospective payment system effective January 1, 2011.

Section 413.230

Determining the per treatment payment amount.

Section 413.231

Adjustment for wages.

Section 413.232

Low-volume adjustment.

Section 413.233

Additional facility-level adjustments.

Section 413.234

Drug designation process.

Section 413.235

Patient-level adjustments.

Section 413.236

Transitional add-on payment adjustment for new and innovative equipment and supplies.

Pharmacy arrangements.

Eligibility for prospectively determined payment rates.

Section 413.308

Rules governing election of prospectively determined payment rates.

Section 413.310

Basis of payment.

Section 413.312

Methodology for calculating rates.

Section 413.314

Determining payment amounts: Routine per diem rate.

Section 413.316

Determining payment amounts: Ancillary services.

Section 413.320

Publication of prospectively determined payment rates or amounts.

Section 413.321

Simplified cost report for SNFs.

Methodology for calculating the prospective payment rates.

Section 413.338

Skilled nursing facility value-based purchasing program.

Section 413.340

Transition period.

Section 413.343

Resident assessment data.

Section 413.345

Publication of Federal prospective payment rates.

Section 413.348

Limitation on review.

Section 413.350

Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A services.

Section 413.355

Additional payment: QIO reimbursement for cost of sending records electronically or by photocopy and mailing.

Section 413.360

Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).

AKI dialysis payment rate.

Section 413.373

Other adjustments to the AKI dialysis payment rate.

Section 413.374

Renal dialysis services included in the AKI dialysis payment rate.

Section 413.375

Notification of changes in rate-setting methodologies and payment rates.

Section 413.400

Definitions.

Section 413.402

Organ acquisition costs.

Section 413.404

Standard acquisition charge.

Section 413.406

Acquisition of pancreata for islet cell transplant.

Intent to transplant, intent for research, counting en bloc, and unusable organs.

Section 413.414

Medicare secondary payer and organ acquisition costs.

Section 413.416

Organ acquisition charges for kidney-paired exchanges.

Section 413.418

Amounts billed to organ procurement organizations for hospital services provided to deceased donors and included as organ acquisition costs.

Section 413.420

Payment to independent organ procurement organizations and histocompatibility laboratories for kidney acquisition costs.