When to Make Spell of Illness Certification

2164 - When to Make Spell of Illness Certification (Rev. 1, 05-21-04) It is not necessary that the SA makes §1861(e)(1) or §1819(a)(1) determinations for Medicare-certified hospitals or Medicare-certified SNFs. Section 1861(e)(1) of the Act contains a basic definition that all hospitals meet. Similarly, §1819(a)(1) of the Act contains the statutory definition of a SNF, which is the basis for Medicare certification requirements of SNFs in 42 CFR 483, Subpart B. In many States, licensing laws for all nursing homes have incorporated the requirements of §1819(a) or §1919(a) of the Act or the criteria contained in §2166. When this is the case, any nursing home licensed in such States cannot be considered a resident’s home for purposes of spell of illness, DME, ambulance, and HHA benefits. In other States it may be necessary for the SA to make §1861(e)(1) or §1819(a)(1) certifications, as appropriate, in the following instances: • Nonparticipating parts of newly certified Medicare distinct part SNFs; • Nonparticipating parts of Medicare SNFs that change from complete to distinct part certifications or that change the size or location of the participating distinct part; • Terminated, denied, or withdrawn Medicare SNFs; • New institutions offering any level of nursing care or rehabilitation which do not intend to participate in Medicare; • Changes in the §1819(a)(1) status of facilities that come to the SA’s attention through licensure, surveys, or other means; and • Parts of hospitals providing patient care but not rendering hospital services. Routine periodic recertifications of spell of illness requirements are not required.