Purpose of Certifying §§1861(e)(1) and 1819(a)(1) of the Act

2160 - Purpose of Certifying §§1861(e)(1) and 1819(a)(1) of the Act Status of Hospitals and SNFs (Rev. 1, 05-21-04) 2160A - Benefit Period Provision (Rev. 1, 05-21-04) A Medicare beneficiary is limited to a specific maximum number of days of covered inpatient hospital care and covered post-hospital extended care in a SNF within a period of time known as a spell of illness or benefit period. Once these benefit days have been used, additional benefit days are not available until the spell of illness ends and a new benefit period begins. Section 1861(a) of the Act defines the term “spell of illness” and states that to end a spell of illness, a beneficiary must not have been an inpatient of any hospital as defined in §1861(e)(1) of the Act or a resident of a facility described in §1819(a)(1) (formerly §1861(j)(1)) of the Act for 60 consecutive days. NOTE: Section 1819(a)(1) of the Act’s basic definition of a SNF for spell of illness purposes was formerly contained in §1861(j)(1) of the Act. Thus, a reference to §1861(j)(1) of the Act in older material should be read as a reference to §1819(a) of the Act. Therefore, to enable beneficiaries, providers, and intermediaries to ascertain eligibility for additional benefits, classify institutions to which a beneficiary may have been removed on the basis of whether the institutions meet the §§1861(e)(1) or 1819(a) definitions. 2160B - Defining Medicare Eligible Individual’s “Home” for Purposes of Durable Medical Equipment (DME) and Home Health Benefits (Rev. 1, 05-21-04) Sections 1861(s)(6) and 1861(n) of the Act provide that purchase or rental of DME such as iron lungs, oxygen tents, hospital beds, or wheelchairs may be covered under Part B of the Medicare program if used in the patient’s home. Similarly, home health benefits can be paid for certain services that are furnished in a patient’s home. An institution that meets the requirements of §1861(e)(1) or §1819(a)(1) of the Act cannot be considered a patient’s home for purposes of this benefit. If a facility is certified as a hospital, a Medicare SNF, or any other facility that meets the requirements of §1861(e)(1) or §1819(a)(1) of the Act, it is not considered the patient’s home. Therefore, the institution’s §1861(e)(1) or §1819(a)(1) status is used for these purposes also. 2160C - Defining “Institution” for Ambulance Benefit (Rev. 1, 05-21-04) Another use of §1861(e)(1) or §1819(a)(1) of the Act’s definitions is to help determine whether ambulance benefits can be paid. The benefit requires that transportation be to or from an institution (i.e., other than the patient’s “home”).