[Federal Register Volume 59, Number 29 (Friday, February 11, 1994)]
[Unknown Section]
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From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-2680]
[[Page Unknown]]
[Federal Register: February 11, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 400, 410, 413, 489, and 498
[BPD-736-IFC]
RIN 0938-AF53
Medicare Program; Partial Hospitalization Services in Community
Mental Health Centers
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Interim final rule with comment period.
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SUMMARY: This rule sets forth the coverage criteria and payment
methodology for partial hospitalization services in community mental
health centers. The purpose of this rule is to establish regulations
governing this coverage under the provisions of section 4162 of the
Omnibus Budget Reconciliation Act of 1990.
DATES: Effective date: These rules are effective February 11, 1994.
Comment date: Comments will be considered if we receive them at the
appropriate address, as provided below, no later than 5 p.m. on April
12, 1994.
ADDRESSES: Mail an original and three copies of comments to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPD-736-IFC, P.O. Box 7517,
Baltimore, MD 21207-0517.
If you prefer, you may deliver your written comments to one of the
following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore,
MD 21207.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-736-IFC. Comments received timely will be available
for public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in room 309-G of
the Department's offices at 200 Independence Avenue, SW., Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(phone: (202) 690-7890).
If you wish to submit comments on the information collection
requirements contained in this interim final rule with comment period,
you may submit comments to: Allison Herron Eydt, HCFA Desk Officer,
Office of Information and Regulatory Affairs, room 3002, New Executive
Office Building, Washington, DC 20503.
FOR FURTHER INFORMATION CONTACT: Regina Walker, (410) 966-6735.
SUPPLEMENTARY INFORMATION:
I. Background
Community mental health centers (CMHCs) provide treatment and
services to mentally ill individuals, including the elderly and
children, residing in the community. The Community Mental Health
Centers Act (Pub. L. 88-164, enacted October 31, 1963) created a
Federal grant program to help States in the construction of CMHCs. The
Community Mental Health Centers Amendments of 1975 (Pub. L. 94-63,
enacted July 29, 1975) specified requirements for CMHCs. The Community
Mental Health Centers Extension Act of 1978 (Pub. L. 95-622, enacted
November 9, 1978) expanded CMHC services to include programs for the
prevention and treatment of alcohol and drug abuse and rehabilitation
of alcohol and drug abusers.
The Public Health Service (PHS) has primary responsibility for
regulating CMHCs. Section 1916(c)(4) of the PHS Act (42 U.S.C. 300x-
4(c)(4)) requires a CMHC to provide specialized outpatient services;
24-hour-a-day emergency care services; day treatment, other partial
hospitalization services, or psychosocial rehabilitation services;
screenings to determine appropriateness of admission to State mental
health facilities; and consultation and education services.
According to the National Council of Community Mental Health
Centers, there are approximately 2,310 CMHCs funded through block
grants to States, and 80 percent of them provide partial
hospitalization services. Before the Omnibus Budget Reconciliation Act
of 1990 (OBRA '90), Public Law 101-508, enacted on November 5, 1990,
partial hospitalization services provided by CMHCs were not covered
under the Medicare program.
Medicare coverage of partial hospitalization services provided by a
hospital to its outpatients became effective December 22, 1987, under
section 1861(ff) of the Social Security Act (the Act), which defines
partial hospitalization services. Section 1861(ff) of the Act was
enacted by section 4070(b)(2) of the Omnibus Budget Reconciliation Act
of 1987 (Pub. L. 100-203) and corrected by section 411(h)(1)(B) of the
Medicare Catastrophic Coverage Act of 1988 (Pub. L. 100-360). Hospital
outpatient departments do not need to qualify as CMHCs to continue to
provide partial hospitalization services.
II. Legislative Changes
Section 4162 of OBRA '90 amended sections 1861(ff) and 1832(a)(2)
of the Act to extend Medicare coverage and payment to partial
hospitalization services provided by CMHCs on or after October 1, 1991.
Section 4162(a) of OBRA '90 amended section 1861(ff) of the Act
concerning partial hospitalization services as follows:
Paragraph (ff)(3), which describes a partial
hospitalization program, was redesignated as subparagraph (ff)(3)(A)
and amended to include a partial hospitalization program provided by a
CMHC.
Subparagraph (ff)(3)(B) was added to define the term CMHC
as an entity that provides the services described in section 1916(c)(4)
of the Public Health Service Act and meets applicable licensing or
certification requirements for CMHCs in the State in which it is
located.
Section 4162(b)(1) of OBRA '90 made conforming changes to section
1832(a)(2) of the Act, which describes the scope of benefits covered
under Supplementary Medical Insurance Benefits for the Aged and
Disabled (Part B) of Medicare, by adding subsection (a)(2)(J) which
refers to partial hospitalization services provided by a CMHC as
described in section 1861(ff)(3)(A) of the Act.
Section 4162(b)(2) of OBRA '90 amended the term ``provider of
services'' described in section 1866(e) of the Act to permit a CMHC to
enter into a Medicare provider agreement but only with respect to
providing partial hospitalization services to Medicare beneficiaries as
described in section 1861(ff)(1) of the Act.
The provisions of section 4162 of OBRA '90 are effective for
services furnished on or after October 1, 1991. The following Medicare
manual instructions have been issued covering partial hospitalization
services in CMHCs:
A. Medicare Intermediary Manual, Part 3--Claims Process, and Medicare
Outpatient Physical Therapy and Comprehensive Outpatient Rehabilitation
Facility Manual, (the same transmittal number and issue date were used
for both manual issuances) Transmittal No. IM-92-1, issued March 1992:
New Procedures--Effective Date: October 1, 1991, concerning partial
hospitalization services provided by CMHCs and bill review instructions
for these services.
B. Medicare Provider Reimbursement Manual, Part 1, Transmittal No. 366,
issued March 1992: New Implementing Instructions--Effective Date:
October 1, 1991, concerning CMHCs as providers of services, the interim
rates for partial hospitalization services provided in CMHCs, and the
interim rate for the initial reporting period for these services in
CMHCs.
III. Current Regulations
Pertinent regulations regarding partial hospitalization services
appear in title 42 of the Code of Federal Regulations (CFR) at the
following locations:
A. Part 410 specifies the benefits, conditions for payment and
limitations on services available under Medicare Part B. Section 410.2
contains a definition of partial hospitalization services.
B. Part 424 contains the specific conditions and limitations applicable
to providers under Medicare Part B. Section 424.24(a) specifies that
partial hospitalization services are not exempt from physician
certification requirements. Section 424.24(e) describes the physician
certification and plan of treatment requirements for partial
hospitalization services.
IV. Provisions of This Interim Final Rule With Comment Period
In accordance with the provisions of section 4162 of OBRA '90, we
are making the changes described below to the Medicare regulations in
title 42 of the CFR. In addition, we are making other minor technical
and conforming changes.
In Sec. 400.202 (Definitions specific to Medicare), we are revising
the definition of ``Provider'' to include a CMHC that has in effect an
agreement to participate in Medicare, but only to provide partial
hospitalization services. We are also revising this definition by
adding ``occupational therapy'' to the list of covered services
furnished by a clinic, rehabilitation agency or public health agency.
These revisions are made in accordance with section 1866(e) of the Act,
which includes a CMHC as a ``provider of services'' but only with
respect to providing partial hospitalization services. Section 1866(e)
of the Act also lists ``occupational therapy'' as a covered service
provided by the aforementioned facilities.
We are revising Sec. 410.2 (Definitions for purposes of Part B of
Medicare) as follows:
We are rearranging the definitions in alphabetical order.
To improve readability we are revising the definition of
``partial hospitalization services'' by removing the list of services
contained in the current definition and adding a cross-reference to a
new Sec. 410.43 which lists the services. Under the revised definition,
partial hospitalization services means a distinct and organized
intensive ambulatory treatment program that offers less than 24-hour
daily care and provides the services specified in Sec. 410.43. This
definition applies to Part B partial hospitalization services provided
by both hospitals and CMHCs.
The definition of ``nominal charge provider''
inadvertently contains the definition for ``participating'', which
includes a definition of a ``nonparticipating'' provider under
Medicare. To correct this, we are removing the definition of
``participating'' provider (including ``nonparticipating'' provider)
and listing it as a separate definition in this section. Concurrently,
in accordance with section 1866(e) of the Act concerning Medicare
provider agreements, we are revising the definition of
``participating'' provider to include a CMHC as a provider of services
that has entered into a Medicare provider agreement, but only to
provide partial hospitalization services.
We are also adding a definition for a CMHC. We define a
CMHC as an entity that provides: Outpatient services, including
specialized outpatient services for children, the elderly, individuals
who are chronically mentally ill, and residents of its mental health
service area who have been discharged from inpatient treatment at a
mental health facility; 24-hour-a-day emergency care services; day
treatment or other partial hospitalization services, or psychosocial
rehabilitation services; screening for patients being considered for
admission to State mental health facilities to determine the
appropriateness of such admission; and consultation and education
services. The definition specifies that a CMHC must also meet
applicable licensing or certification requirements for CMHCs in the
State in which it is located.
This new definition is based upon section 1861(ff)(3)(B) of the
Act, which defines a CMHC as an entity that: (1) Provides the services
described in section 1916(c)(4) of the PHS Act; and (2) meets
applicable State licensing or certification requirements. In the CMHC
definition at Sec. 410.2, we are listing the required services as they
appear in section 1916(c)(4) of the PHS Act.
In Sec. 410.3 (Scope of benefits), we are revising subparagraph
(a)(2) to include partial hospitalization services provided by a CMHC
as services covered under Part B of Medicare. This revision is made in
accordance with section 1832(a)(2)(J) of the Act, which includes
partial hospitalization services in a CMHC in the scope of Medicare
Part B benefits.
In a new Sec. 410.43 (Partial hospitalization services: Conditions
and exclusions.), in paragraph (a), we list the services that are
described as partial hospitalization services, based on section
1861(ff)(2) of the Act. We specify that to be considered a partial
hospitalization service, a service must be reasonable and necessary for
the diagnosis or active treatment of the individual's condition and
reasonably expected to improve or maintain the individual's condition
and functional level and to prevent relapse or hospitalization. In
addition, the service must be one of the following:
Individual and group therapy with physicians or
psychologists or other mental health professionals to the extent
authorized under State law.
Occupational therapy requiring the skills of a qualified
occupational therapist.
Services of social workers, trained psychiatric nurses,
and other staff trained to work with psychiatric patients.
Drugs and biologicals furnished for therapeutic purposes,
subject to the limitations described in Sec. 410.29.
Individualized activity therapies that are not primarily
recreational or diversionary.
Family counseling, the primary purpose of which is
treatment of the individual's condition.
Patient training and education, to the extent the training
and educational activities are closely and clearly related to the
individual's care and treatment.
Diagnostic services.
Other items and services as specified by HCFA, excluding
meals and transportation.
Some services in this description are separately covered and paid
as the professional services of independent practitioners. In order to
determine how to handle the services of certain nonphysician
practitioners, we have examined the statutory provisions that
established the hospital outpatient department coverage of partial
hospitalization services, since the Congress built upon these
provisions to extend Medicare Part B coverage to a CMHC as a provider
of partial hospitalization services. Also applicable, therefore, are
the statutory provisions governing the methodology by which physicians
and others are paid for their services furnished in hospital settings.
Below we reference four sections of the Act, which, while
pertaining expressly to the services of a professional in the context
of a hospital, we believe serve as a model for the coverage of the
services of a clinical psychologist (CP) and a physician assistant (PA)
when those professionals furnish services in a CMHC.
Section 1861(b)(4) of the Act excludes medical or surgical
services furnished by a physician, resident or intern, and services
furnished by a CP and PA from the term ``inpatient hospital services''.
(Services of a certified nurse midwife and a certified registered nurse
anesthetist are also excluded from the definition of inpatient hospital
services, but our focus is on CPs and PAs because the other
nonphysician practitioners are less likely to furnish services in a
CMHC, based on the types services that are covered as partial
hospitalization services.)
Section 1832(a)(2)(B) of the Act excludes from the scope
of medical and other health services furnished by a provider, physician
services and services of certain nonphysician practitioners, including
CPs. (A CMHC is considered a ``provider of services'' under section
1866(e)(2) of the Act for the purpose of providing partial
hospitalization services.) This means these services are excluded from
the scope of outpatient hospital services and partial hospitalization
services because they are separately paid for by Medicare Part B under
section 1832(a)(1) of the Act.
Sections 1862(a)(14) and 1866(a)(1)(H) of the Act specify
that services by a physician and a CP and PA are not included in
payments made to a hospital (either on an inpatient or outpatient
basis) for certain services. Consequently, these services that are
``unbundled'' from hospital payment can be billed directly by a CP and
the employer of a PA to Medicare Part B, and are paid separately.
Before 1986, the bundling provisions referred solely to inpatient
services. However, section 9343(c)(2)(B) of the Omnibus Budget
Reconciliation Act of 1986 (Pub. L. 99-509) amended section
1866(a)(1)(H) of the Act by striking the phrase ``an inpatient'' and
inserting the phrase ``a patient''. Therefore, the reference to
``unbundled'' services pertains to services furnished either to
inpatients or outpatients.
Sections 1861(ii) and 1861(s)(2)(K)(i) of the Act enable a CP and
PA to furnish services that would otherwise be furnished by a
physician. Accordingly, since these practitioners' services are
separately covered and no longer considered to be part of a hospital's
services, including its partial hospitalization services, we are
providing that the services of a CP and PA are also unbundled when
furnished in a CMHC. Thus, these practitioners can bill Medicare Part B
directly for their professional services furnished to hospital patients
and to CMHC partial hospitalization patients.
Consequently, we are adding a new Sec. 410.43(b) to our regulations
to specify that the following services are not paid as partial
hospitalization services:
Physician services that meet the criteria of part 405,
subpart F for payment on a fee schedule basis in accordance with part
414.
Clinical psychologist services, as defined in section
1861(ii) of the Act, that are furnished after December 31, 1990.
Physician assistant services, as defined in section
1861(s)(2)(K)(i) of the Act, that are furnished after December 31,
1990.
Accordingly, when furnishing services to partial hospitalization
patients in a CMHC, the professionals specified in Sec. 410.43(b) may
bill Medicare Part B for their services by submitting their claims
directly to the Medicare Part B carrier. The CMHC can also serve as a
billing agent for these professionals, by billing the Part B carrier on
their behalf for their professional services furnished at the CMHC.
Conversely, there are some independent practitioners whose services
are bundled when furnished to hospital patients; for example, clinical
social workers (CSWs). In accordance with section 1861(hh)(2) of the
Act, a CSW is not authorized to bill directly for services furnished to
patients in a hospital and skilled nursing facility that are Medicare
participating. Therefore, for CSWs or other practitioner's services
that remain bundled when furnished in the hospital setting, we are
providing that these services are also bundled in the CMHC setting.
Accordingly, the CMHC must bill intermediaries for nonphysician
practitioner services listed under Sec. 410.43(a), and the
intermediaries will make payment for the services to the CMHC on a
reasonable cost basis.
To accommodate the new partial hospitalization services benefit in
a CMHC and to allow for future expansion of part 410, we are
redesignating existing subpart E regarding payment of supplementary
medical insurance benefits as subpart I, adding and reserving subparts
F through H for future regulations, and adding a new subpart E
concerning partial hospitalization services provided in a CMHC.
In the new subpart E in Sec. 410.110, we specify the requirements
for coverage of partial hospitalization services in a CMHC. We state
that Medicare Part B covers partial hospitalization services when they
are furnished directly by, or under arrangements made by, a CMHC as
defined in Sec. 410.2 that has in effect a provider agreement to
participate in Medicare. In this context, ``under arrangements''
describes situations in which: (1) A CMHC makes contractual
arrangements with another entity or practitioners to come into the CMHC
to furnish partial hospitalization services; and (2) Medicare makes
payment for the services to the CMHC. We have provided that a CMHC can
provide partial hospitalization services under arrangements based on
section 1861(ff) of the Act, which treats a CMHC and a hospital as
comparable providers of partial hospitalization services. Since a
hospital is permitted to furnish services under arrangements, we
believe that a CMHC should be treated similarly in this respect. As
noted above, we believe that the Congress intended that the scope of
the partial hospitalization benefit in a CMHC would generally follow
the scope of the benefit as we have implemented it for hospital
providers. We especially invite comment on this approach of using the
precedents established for hospital providers of partial
hospitalization services as a model for Part B coverage and payment of
the same services in a CMHC context.
In Sec. 410.110(a), we require that partial hospitalization
services be prescribed by a physician and furnished under the general
supervision of a physician. We considered whether the services of a
full time physician were required to implement the statutory
requirement under section 1861(ff)(1) of the Act for physician
supervision of partial hospitalization services under a written plan of
treatment. We recognize that such a requirement could cause hardship to
CMHCs because some of these entities are unable to employ physicians on
a full-time basis because of the expense involved. Therefore, because
we believe that less than direct supervision by a full-time physician
in a CMHC would not jeopardize a patient's health or treatment program,
and there would be a number of professionals involved in the care of
the patient who have been authorized to furnish services that would
otherwise be furnished by a physician, we are requiring general
physician supervision. This means that a physician must at least be
available by telephone but is not required to be present on the
premises of the CMHC at all times.
Physician certification is required under the procedures for
payment of claims to providers of partial hospitalization services
under section 1835(a)(2)(F) of the Act. Hence, in Sec. 410.110(b), we
require that physician certification of the need for partial
hospitalization services in a CMHC comply with the certification
requirements in existing Sec. 424.24(e)(1). These requisites, which
apply to partial hospitalization services provided by hospitals, are
that:
A physician certifies that the individual would require
inpatient psychiatric care in the absence of partial hospitalization
services.
The partial hospitalization services are being or were
furnished while the individual is or was under the care of a physician.
The services are or were furnished under a written plan of
treatment.
In Sec. 410.110(c), we specify that the CMHC partial
hospitalization services must be furnished under a plan of treatment as
described in existing Sec. 424.24(e)(2). This requirement is also based
on sections 1861(ff)(1) and 1835(a)(2)(F) of the Act which require that
partial hospitalization services be furnished under an individualized,
written plan of treatment established and periodically reviewed by a
physician (in consultation with appropriate staff participating in such
a program). The plan must set forth: (1) The physician's diagnosis; (2)
the type, amount, duration, and frequency of the services; and (3) the
goals for treatment. These same plan of treatment requirements apply to
partial hospitalization services provided by a hospital.
Existing Sec. 410.150, which specifies to whom payment is made,
will now be included under redesignated subpart I (Payment of SMI
(Supplementary Medical Insurance) Benefits). We add a new
Sec. 410.150(b)(13) to apply the specific rules governing Medicare Part
B payments to a CMHC. The rules are that Medicare Part B pays a CMHC on
an individual's behalf, for partial hospitalization services provided
by the CMHC, or by others under arrangements made with them by the
CMHC. We are reserving Sec. 410.150(b)(12) for future use.
Section 4162 of OBRA '90 does not explicitly address payment
requirements for partial hospitalization services provided by a CMHC.
The applicable statutory references regarding payment of SMI benefits
are contained in sections 1833 and 1835 of the Act.
Section 1833 of the Act describes payment for Medicare Part B
services and section 1835 of the Act specifies the procedures for
payment of claims of providers of services.
Specifically, section 1833(a)(2)(B) of the Act governs payment for
partial hospitalization services provided by a CMHC. In accordance with
this section, payment to a CMHC for partial hospitalization services is
to be made:
(1) At the lesser of: (a) The reasonable cost of such services, as
determined under section 1861(v) of the Act; or (b) the customary
charges with respect to such services, less the amount a provider may
charge as described in clause (ii) of section 1866(a)(2)(A) of the Act
(``coinsurance''), but in no case may the payment for such other
services exceed 80 percent of such reasonable cost; or
(2) If such services are provided by a public provider of services,
or by another provider which demonstrates to the satisfaction of the
Secretary that a significant portion of its patients are low-income
(and requests that payment be made under this clause), free of charge
or at nominal charges to the public, payment is made at 80 percent of
the amount determined in accordance with section 1814(b)(2) of the Act;
that is, the provider's ``reasonable cost''.
Section 1833(a)(2)(B) of the Act also provides that if (and for so
long as) the conditions described in section 1814(b)(3) of the Act are
met, payment is made in the amounts determined under the reimbursement
system described in such section. We believe that this provision is not
applicable to CMHC payment since section 1814(b)(3) of the Act
addresses payment to hospital providers in a State with a demonstration
project involving an approved State reimbursement cost control system.
We are revising the heading of Sec. 410.155 from ``Psychiatric
services limitations: Expenses incurred for physician services and CORF
services.'' to ``Outpatient mental health treatment limitation.'' since
this section focuses on treatment services and not diagnostic services.
For clarity, we are also revising Sec. 410.155(b) to specify the
services subject to the outpatient mental health treatment limitation
in Sec. 410.155(c), which reflects section 1833(c) of the Act. These
are services for the treatment of a mental, psychoneurotic, or
personality disorder furnished to an individual who is not an inpatient
of a hospital and include the following:
(1) CORF services.
(2) Physicians' services that meet the criteria of part 405,
subpart F for payment on a fee schedule basis in accordance with part
414.
(3) Physician assistant services, as defined in section
1861(s)(2)(K)(i) of the Act, that are furnished after December 31,
1990.
(4) Clinical psychologist services, as defined in section 1861(ii)
of the Act, that are furnished after December 31, 1990.
Section 1833(c) of the Act exempts partial hospitalization services
that are not directly furnished by a physician from the outpatient
mental health treatment limitation. The nonphysician practitioners
specified in Sec. 410.155(b) who furnish services to partial
hospitalization patients in a CMHC are furnishing services that would
otherwise be furnished by physicians and, like physicians, may bill
Medicare directly for Part B services. The professional services
furnished by these practitioners in a CMHC are not partial
hospitalization services and, therefore, are subject to the outpatient
mental health treatment limitation of Sec. 410.155. A discussion of the
professional services of these practitioners and the method of payment
for their services was presented in more detail in the explanation of
Sec. 410.43(b) presented earlier in this preamble.
Conversely, services furnished by any nonphysician practitioner not
shown in Sec. 410.43(b) (for example, a clinical social worker) to a
partial hospitalization patient in a CMHC are considered partial
hospitalization services and, therefore, are not subject to the
outpatient mental health treatment limitation.
In a newly added Sec. 410.172, we specify the conditions for
payment of partial hospitalization services in a CMHC. In paragraph
(a), we state that Medicare Part B pays for partial hospitalization
services provided in a CMHC only if a written request for payment is
filed by the CMHC. (The form to be used is UB-92, HCFA 1450.) In
Sec. 410.172(b), we require that partial hospitalization services in a
CMHC are provided in accordance with the conditions described in
Sec. 410.110, which require that the services must be:
Prescribed by a physician and furnished under the general
supervision of a physician (section 1861(ff)(1) of the Act);
Subject to certification by a physician in accordance with
Sec. 424.24(e)(1) (section 1835(a)(2)(F) of the Act); and
Furnished under a plan of treatment that meets the
requirements of Sec. 424.24(e)(2) (section 1861(ff)(1) of the Act).
In part 413, subpart A, concerning the general rules of reasonable
cost reimbursement, we are adding CMHCs to the list of providers
described in Sec. 413.1 as authorized to receive Medicare payment for
services provided to beneficiaries. In Sec. 413.13(b) under the rules
for applying the principle of lesser of costs or charges, we are adding
CMHCs to the list of providers under the general rule regarding payment
under reasonable cost reimbursement, but only with regard to providing
partial hospitalization services. OBRA '90 did not address payment to a
CMHC. However, as presented earlier in the discussion of the changes to
Sec. 410.150, the general payment principles of section 1833(a) apply
to a CMHC, and they are the basis for our changes to part 413.
In part 489 concerning provider agreements under Medicare, in
Sec. 489.2 (Scope of part), we list a CMHC as a provider of services
authorized to participate in Medicare, but only for purposes of
providing partial hospitalization services in accordance with section
1866(e)(2) of the Act. As a provider of partial hospitalization
services, a CMHC is subject to the rules governing Medicare provider
agreements. To conform the newly designated Sec. 489.2(c)(1) to section
1866(e)(1) of the Act, we are also adding ``occupational therapy'' to
the list of covered services furnished by clinics, rehabilitation
agencies, and public health agencies.
Under the basic requirements in Sec. 489.10 and the reasons for
denying participation in Medicare in Sec. 489.12, we are making a
technical change in the references to the civil rights requirements. In
accordance with 45 CFR part 84, appendix A, subpart A, Medicare Part B
does not constitute Federal financial assistance, and, thus, these
providers are not subject to the civil rights requirements.
Although we are not revising Sec. 489.11 (Acceptance of a provider
as a participant), the provisions of this section apply to a CMHC. We
are in the process, however, of developing a new provider agreement
specific to a CMHC. In the interim, if a CMHC desires to participate in
the Medicare program, it must submit a letter requesting approval as a
CMHC. The letter requesting approval as a CMHC is considered an
official application and must be accompanied by a signed attestation
statement that the CMHC complies with all Federal requirements
described in section 1861(ff)(3)(B) of the Act and conforms to the
provisions of section 1866 of the Act concerning Medicare provider
agreements. If HCFA determines that the CMHC meets all Federal
requirements, the CMHC receives notification of approval and the CMHC
is assigned a provider number.
In Sec. 489.13 (Effective date of agreement), we are modifying
paragraphs (a) and (b) to refer to a new paragraph (c) that specifies
the effective date of a provider agreement with a CMHC. Since a CMHC is
not subject to an onsite survey by a Federal or State agency surveyor
(see 42 CFR part 488), the effective date of its provider agreement is
based on receipt of its request to participate in Medicare and
compliance with all Federal requirements. In order to assure coverage
of these CMHC services on the effective date of the law, we are
providing that, for requests for Medicare participation received before
July 1, 1992, if the CMHC met all Federal requirements by October 1,
1991, and the CMHC selects this date as the effective date, the
agreement is effective for services provided on or after October 1,
1991, the statutory effective date for coverage of partial
hospitalization benefits in a CMHC (section 4162 of OBRA '90) (or such
later date as requested by the provider). If Federal requirements were
not met on October 1, 1991, the agreement is effective on the date the
requirements are met. For requests for Medicare participation received
after June 30, 1992, the agreement is effective on the date the CMHC
meets all Federal requirements but not before the date HCFA receives
the application. The June 30 and July 1, 1992, dates are the same dates
contained in the certification package that was sent to all CMHCs
requesting participation in the Medicare program.
Section 1866(e) of the Act includes a CMHC as a provider of
services but only for purposes of providing partial hospitalization
services. Therefore, we are amending part 498 concerning appeals
procedures for determinations that affect participation in the Medicare
program. Specifically, in Sec. 498.2 (Definitions), we are adding CMHC
to the definition of ``Provider''. (This is the same definition that
appears at revised Sec. 400.202.) Thus, a CMHC is entitled to a hearing
and judicial review of the hearing decision if it is dissatisfied with
a determination that it is not a provider, or with any determination
described in section 1866(b)(2) of the Act that gives the Secretary the
authority to refuse participation in Medicare to a provider failing to
meet certain conditions. As a conforming change to the definition of
``Provider'' at Sec. 489.2, we are adding ``occupational therapy'' to
the list of covered services furnished by clinics, rehabilitation
agencies, and public health agencies in accordance with section
1866(e)(1) of the Act. For ease of reference, we are also eliminating
the separate definition of ``prospective supplier'' but incorporating
its contents as it currently appears in this section into the
definition of ``Supplier.'' This format is consistent with other
definitions throughout Chapter IV of Title 42.
V. Collection of Information Requirements
Regulations at Secs. 410.172, 413.20, and 489.11 contain
information collection or recordkeeping requirements or both that are
subject to review by the Office of Management and Budget (OMB) under
the Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.). Section
410.172 concerns information collection requirements related to
submitting the UB-92 form (HCFA-1450), the written request for payment
that CMHCs must submit when billing for partial hospitalization
services. We have determined that the annual burden for collecting this
information is 4.9 hours per CMHC. Thus, based on an estimate of 2,000
participating CMHCs, the annual burden for submission of the UB92 is
approximately 9,870 hours (4.9 hours per year x 2,000 CMHCs). The
information collection requirements in Sec. 410.172 have been approved
by OMB (control number 0938-0279).
Section 413.20 concerns information collection and recordkeeping
requirements associated with the requirement that CMHCs submit an
annual cost report in order to receive Medicare payment for partial
hospitalization services. We have determined that the annual burden for
this cost reporting requirement is 140 hours per CMHC. Therefore, the
estimated annual burden for CMHCs is 280,000 hours (140 hours per year
x 2,000 CMHCs). Additionally, Sec. 489.11 contains information
collection and recordkeeping requirements related to the application
and signed attestation statement that CMHCs must submit to request
approval to participate in the Medicare program as a provider of
partial hospitalization services. The CMHC must attest that it complies
with the Federal requirements described in section 1861(ff)(3)(B) of
the Act and conforms to the provisions of section 1866 of the Act
concerning Medicare provider agreements. The annual burden for
completing the application and attestation statement is 10 minutes per
CMHC. Therefore, the annual burden for CMHCs is approximately 333 hours
(10 minutes per year x 2,000 CMHCs). The information collection and
recordkeeping requirements associated with Secs. 413.20 and 489.11 have
been sent to OMB for approval in accordance with the Paperwork
Reduction Act and will not be effective until OMB approval is received.
Organizations and individuals desiring to submit comments on the
information collection and recordkeeping requirements in Secs. 413.20
or 489.11 should direct then to the OMB official whose name appears in
the ADDRESSES section of this preamble.
VI. Waiver of Proposed Rulemaking and of Delayed Effective Date
In accordance with the statutory effective date of October 1, 1991,
coverage of partial hospitalization services in a CMHC has been
available to Medicare beneficiaries since that date. Nonetheless,
because the Secretary is exercising discretion in implementing section
4162 of OBRA '90, ordinarily we would publish a notice of proposed
rulemaking and afford a period for public comment. However, section
4207(j) of OBRA '90 permits the Secretary to issue interim final
regulations with a comment period (without prior notice and comment) to
implement any of the provisions of OBRA '90 that affect the Medicare
and Medicaid programs. Therefore, we are using that authority to
publish this interim final rule with comment period.
VII. Response to Comments
Because of the large number of items of correspondence we normally
receive on a interim final rule with comment period, we are not able to
acknowledge or respond to them individually. However, we will consider
all comments that we receive by the date and time specified in the
DATES section of this preamble, and we will respond to the comments in
the preamble to the final rule.
VIII. Impact Statement
Unless the Secretary certifies that a proposed rule would not have
a significant economic impact on a substantial number of small
entities, we generally prepare a regulatory flexibility analysis that
is consistent with the Regulatory Flexibility Act (RFA) (5. U.S.C. 601
through 612). For purposes of the RFA, all CMHCs are considered to be
small entities.
Also, section 1102(b) of the Act requires the Secretary to prepare
a regulatory impact analysis if an interim final rule with comment
period may have a significant impact on the operations of a substantial
number of small rural hospitals. This analysis must conform to the
provisions of section 604 of the RFA. For purposes of section 1102(b)
of the Act, we define a small rural hospital as a hospital that is
located outside of a Metropolitan Statistical Area and has fewer than
50 beds.
This interim final rule with comment period implements the
provisions of section 4162 of OBRA '90, which were effective October 1,
1991. Before enactment of OBRA '90, partial hospitalization services
furnished by a CMHC were not covered under the Medicare program.
According to the National Council of Community Mental Health
Centers, there were 2,310 CMHCs as of 1990, but only 80 percent of
them, 1,848, would have qualified to provide partial hospitalization
services. The average budget for each CMHC for FY 1990 was $3 million,
with only 2 percent being paid by Medicare for eligible beneficiaries
for services furnished by psychiatrists, services incident to
psychiatrist's services, and services that the CMHC billed for on
behalf of clinical psychologists. In addition, very few of the elderly
are in partial hospitalization programs because of the limited capacity
that a CMHC has for Medicare patients. We estimate that, as a result of
the expansion of coverage to include partial hospitalization services,
Medicare payments to CMHCs will increase the first year by 10 percent
over the amount previously paid by Medicare. Thus, the cost of the
additional benefit for FY 1990 would be calculated as follows:
Number of CMHCs qualified to provide partial
hospitalization services............................. 1,848
Average Medicare payment under existing
provisions........................................... x $60,000
-----------------
Estimated FY 1990 Medicare payments................. $110,880,000
Estimated increase in Medicare payments....... x .10
-----------------
Total cost of partial hospitalization benefit
rounded to nearest $5 million........................ $10,000,000
In order to project this estimate forward, we assume continuing
increases of 7 percent per year in the number of CMHCS. Based on this
assumption, the projected costs of this benefit for FYs 1994 through
1998 are as follows:
Estimated Medicare Costs--Partial Hospitalization Services in CMHCs
[In millions of dollars]*
------------------------------------------------------------------------
FY 1994 FY 1995 FY 1996 FY 1997 FY 1998
------------------------------------------------------------------------
$15......................... $15 $15 $15 $20
------------------------------------------------------------------------
*Rounded to the nearest $5 million.
It is estimated that the records maintenance and the record
extraction time needed to complete the CMHC cost report, required to
determine rates for partial hospitalization services, would be
approximately 140 hours, which should not place an undue burden on a
CMHC. The cost report for a CMHC is based on the same cost report that
is currently used by comprehensive outpatient rehabilitation facilities
or facilities furnishing outpatient physical therapy services. It is a
simplified report required by the Medicare program that requests CMHC
costs in order for the intermediaries to calculate payment for partial
hospitalization services. Most of the records needed are currently
maintained by a CMHC.
Coverage of partial hospitalization in a CMHC provides the elderly
with another alternative for treatment of mental illnesses. Not only
will CMHC patient volume and revenue increase, but the CMHC's role as a
health care provider will be enhanced due to the expanded scope of
mental health services covered by the Medicare program.
In conclusion, we are not preparing analyses for either the RFA or
section 1102(b) of the Act since we have determined, and the Secretary
certifies, that this interim final rule with comment period will not
result in a significant economic impact on a substantial number of
small entities and will not have a significant economic impact on the
operations of a substantial number of small rural hospitals.
List of Subjects
42 CFR Part 400
Grant programs-health, Health facilities, Health maintenance
organizations (HMO), Medicaid, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 410
Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Rural areas, X-rays.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 498
Administrative practice and procedure, Health facilities, Health
professions, Medicare, Reporting and recordkeeping requirements.
42 CFR chapter IV is amended as follows:
A. Part 400, subpart B is amended as follows:
PART 400--INTRODUCTIONS; DEFINITIONS
1. The authority citation for part 400 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh) and 44 U.S.C. chapter 35.
2. In Sec. 400.202, the introductory text is republished and the
definition for ``Provider'' is revised to read as follows:
Sec. 400.202 Definitions specific to Medicare.
As used in connection with the Medicare program, unless the context
indicates otherwise--
* * * * *
Provider means a hospital, an RPCH, a skilled nursing facility, a
comprehensive outpatient rehabilitation facility, a home health agency,
or a hospice that has in effect an agreement to participate in
Medicare, or a clinic, a rehabilitation agency, or a public health
agency that has in effect a similar agreement but only to furnish
outpatient physical therapy, or speech pathology services, or a
community mental health center that has in effect a similar agreement
but only to furnish partial hospitalization services.
* * * * *
B. Part 410 is amended as follows:
PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
1. The authority citation for part 410 is revised to read as
follows:
Authority: Secs. 1102, 1832, 1833, 1834, 1835, 1861(r), (s),
(aa), (cc), and (ff), 1871, and 1881 of the Social Security Act (42
U.S.C. 1302, 1395k, 1395l, 1395m, 1395n, 1395x(r), (s), (aa), (cc),
and (ff), 1395hh, and 1395rr).
Subpart I--Payment of SMI Benefits
Sec.
410.150 To whom payment is made.
410.152 Amounts of payment.
410.155 Outpatient mental health treatment limitation.
410.160 Part B annual deductible.
410.161 Part B blood deductible.
410.163 Payment for services furnished to kidney donors.
410.165 Payment for rural health clinic services and ambulatory
surgical center services: Conditions.
410.170 Payment for home health services, for medical and other
health services furnished by a provider or an approved ESRD
facility, and for comprehensive outpatient rehabilitation facility
(CORF) services: Conditions.
410.172 Payment for partial hospitalization services in CMHCs:
Conditions.
410.175 Alien absent from the United States.
3. Section 410.2 is revised to read as follows:
Sec. 410.2 Definitions.
As used in this part--
Community mental health center (CMHC) means an entity that--(1)
Provides outpatient services, including specialized outpatient services
for children, the elderly, individuals who are chronically mentally
ill, and residents of its mental health service area who have been
discharged from inpatient treatment at a mental health facility;
(2) Provides 24-hour-a-day emergency care services;
(3) Provides day treatment or other partial hospitalization
services, or psychosocial rehabilitation services;
(4) Provides screening for patients being considered for admission
to State mental health facilities to determine the appropriateness of
such admission;
(5) Provides consultation and education services; and
(6) Meets applicable licensing or certification requirements for
CMHCs in the State in which it is located.
Nominal charge provider means a provider that furnishes services
free of charge or at a nominal charge, and is either a public provider
or another provider that (1) demonstrates to HCFA's satisfaction that a
significant portion of its patients are low-income; and (2) requests
that payment for its services be determined accordingly.
Partial hospitalization services means a distinct and organized
intensive ambulatory treatment program that offers less than 24-hour
daily care and furnishes the services described in Sec. 410.43.
Participating refers to a hospital, SNF, HHA, CORF, hospice, that
has in effect an agreement to participate in Medicare; or a clinic,
rehabilitation agency, or public health agency that has a provider
agreement to participate in Medicare but only for purposes of providing
outpatient physical therapy, occupational therapy, or speech pathology
services; or a CMHC that has in effect a similar agreement but only for
purposes of providing partial hospitalization services, and
nonparticipating refers to a hospital, SNF, HHA, CORF, hospice, clinic,
rehabilitation agency, public health agency, or CMHC, that does not
have in effect a provider agreement to participate in Medicare.
Sec. 410.3 [Amended]
4. In Sec. 410.3(a)(2), the phrase ``and comprehensive outpatient
rehabilitation facilities (CORFs).'' is revised to read ``comprehensive
outpatient rehabilitation facilities (CORFs), and partial
hospitalization services provided by community mental health centers
(CMHCs).''.
5. A new section Sec. 410.43 is added under subpart B to read as
follows:
Sec. 410.43 Partial hospitalization services: Conditions and
exclusions.
(a) Partial hospitalization services are services that--
(1) Are reasonable and necessary for the diagnosis or active
treatment of the individual's condition;
(2) Are reasonably expected to improve or maintain the individual's
condition and functional level and to prevent relapse or
hospitalization; and
(3) Include any of the following:
(i) Individual and group therapy with physicians or psychologists
or other mental health professionals to the extent authorized under
State law.
(ii) Occupational therapy requiring the skills of a qualified
occupational therapist.
(iii) Services of social workers, trained psychiatric nurses, and
other staff trained to work with psychiatric patients.
(iv) Drugs and biologicals furnished for therapeutic purposes,
subject to the limitations specified in Sec. 410.29.
(v) Individualized activity therapies that are not primarily
recreational or diversionary.
(vi) Family counseling, the primary purpose of which is treatment
of the individual's condition.
(vii) Patient training and education, to the extent the training
and educational activities are closely and clearly related to the
individual's care and treatment.
(viii) Diagnostic services.
(b) The following services are separately covered and not paid as
partial hospitalization services:
(1) Physicians' services that meet the criteria of part 405,
subpart F of this chapter for payment on a fee schedule basis in
accordance with part 414 of this chapter.
(2) Physician assistant services, as defined in section
1861(s)(2)(K)(i) of the Act, that are furnished after December 31,
1990.
(3) Clinical psychologist services, as defined in section 1861(ii)
of the Act, that are furnished after December 31, 1990.
6. Subpart E is redesignated as subpart I.
Subpart E--[Redesignated as Subpart I]
7. A new subpart E consisting of Sec. 410.110 is added to read as
follows:
Subpart E--Community Mental Health Centers (CMHCs) Providing
Partial Hospitalization Services
Sec. 410.110 Requirements for coverage of partial hospitalization
services by CMHCs.
Medicare part B covers partial hospitalization services furnished
by or under arrangements made by a CMHC if they are provided by a CMHC
as defined in Sec. 410.2 that has in effect a provider agreement under
part 489 of this chapter and if the services are--
(a) Prescribed by a physician and furnished under the general
supervision of a physician;
(b) Subject to certification by a physician in accordance with
Sec. 424.24(e)(1) of this subchapter; and
(c) Furnished under a plan of treatment that meets the requirements
of Sec. 424.24(e)(2) of this subchapter.
8. Subparts F through H are added and reserved as follows:
Subparts F through H--[Reserved]
9. In Sec. 410.150, the heading of paragraph (a) is republished,
paragraph (a)(2) is revised, the introductory text of paragraph (b)
introductory text is republished, and a new paragraph (b)(13) is added
to read as follows:
Sec. 410.150 To whom payment is made.
(a) General rules.
* * * * *
(2) The services specified in paragraphs (b)(5) through (b)(13) of
this section must be furnished by a facility that has in effect a
provider agreement or other appropriate agreement to participate in
Medicare.
(b) Specific rules. Subject to the conditions set forth in
paragraph (a) of this section, Medicare Part B pays as follows:
* * * * *
(13) To a community mental health center (CMHC) on the individual's
behalf, for partial hospitalization services furnished by the CMHC (or
by others under arrangements made with them by the CMHC).
10. In Sec. 410.155, the section heading and paragraph (b) are
revised to read as follows:
Sec. 410.155 Outpatient mental health treatment limitation.
* * * * *
(b) Services subject to limitation. The mental health treatment
limitation applies to the following services furnished for the
treatment of a mental, psychoneurotic, or personality disorder, when
the services are furnished to an individual who is not an inpatient in
a hospital:
(1) CORF services.
(2) Physicians' services that meet the criteria of part 405,
subpart F of this chapter for payment on a fee schedule basis in
accordance with part 414 of this chapter.
(3) Physician assistant services, as defined in section
1861(s)(2)(K)(i) of the Act, that are furnished after December 31,
1990.
(4) Clinical psychologist services, as defined in section 1861(ii)
of the Act, that are furnished after December 31, 1990.
* * * * *
11. A new Sec. 410.172 is added to read as follows:
Sec. 410.172 Payment for partial hospitalization services in CMHCs:
Conditions.
Medicare Part B pays for partial hospitalization services furnished
in a CMHC on behalf of an individual only if the following conditions
are met:
(a) The CMHC files a written request for payment on the HCFA form
1450 and in the manner prescribed by HCFA; and
(b) The services are furnished in accordance with the requirements
described in Sec. 410.110.
C. Part 413 is amended as follows:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES
1. The authority citation for part 413 continues to read as
follows:
Authority: Secs. 1102, 1814(b), 1815, 1833(a), (i) and (n),
1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42
U.S.C. 1302, 1395f(b), 1395g, 1395l(a), (i) and (n), 1395x(v),
1395hh, 1395rr, 1395tt, and 1395ww); sec. 104(c) of Pub. L. 100-360,
as amended by sec. 608(d)(3) of Pub. L. 100-485 (42 U.S.C. 1395ww
(note)) and sec. 101(c) of Pub. L. 101-234 (42 U.S.C. 1395ww(note)).
2. In Sec. 413.1, the introductory text of paragraph (a)(1) is
republished; a new paragraph (a)(1)(viii) is added; and paragraph
(a)(2) is revised to read as follows:
Sec. 413.1 Introduction.
(a) Scope.
(1) General summary. This part sets forth regulations governing
Medicare payment for services furnished to beneficiaries by--
* * * * *
(viii) Community mental health centers (CMHCs) but only for
purposes of furnishing partial hospitalization services.
(2) Applicability. The principles of payment and the related
policies described in this part apply to HCFA, to the fiscal
intermediaries acting as payers of claims on HCFA's behalf, to the
Provider Reimbursement Review Board, and to the hospitals, SNF, HHAs,
CORFS, ESRD facilities, OPTs, OPAs, histocompatibility laboratories,
and CMHCs receiving payment under this part.
Sec. 413.13 [Amended]
3. In Sec. 413.13(b)(1), the phrase ``and OPTs'' is revised to read
``OPTs, and CMHCs but only for purposes of providing partial
hospitalization services,''.
D. Part 489 is amended as follows:
PART 489--PROVIDER AND SUPPLIER AGREEMENTS UNDER MEDICARE
1. The authority citation for part 489 continues to read as
follows:
Authority: Secs. 1102, 1861, 1864(m), 1866, and 1871 of the
Social Security Act (42 U.S.C. 1302, 1395x, 1395aa(m), 1395cc, and
1395hh).
2. In Sec. 489.2, the introductory text to paragraph (b) is
republished, a new (b)(8) is added, and paragraph (c) is revised to
read as follows:
Sec. 489.2 Scope of part.
* * * * *
(b) The following providers are subject to the provisions of this
part:
* * * * *
(8) Community mental health centers (CMHCs).
(c)(1) Clinics, rehabilitation agencies, and public health agencies
may enter into provider agreements only for furnishing outpatient
physical therapy, and speech pathology services.
(2) CMHCs may enter into provider agreements only to furnish
partial hospitalization services.
Sec. 489.10 [Amended]
3. In Sec. 489.10(b), the phrase ``The provider must meet the
requirements of:'' is revised to read ``The provider must meet the
applicable civil rights requirements of:''.
Sec. 489.12 [Amended]
4. In Sec. 489.12(c), the phrase ``45 CFR parts 80, 84, and 90.''
is revised to read ``45 CFR parts 80, 84, and 90, subject to the
provisions of Sec. 489.10.''.
5. Section 489.13 is revised to read as follows:
Sec. 489.13 Effective date of agreement.
(a) All Federal requirements are met on the date of the survey.
Except as provided in paragraph (c) of this section, the agreement
is effective on the date the onsite survey is completed (or on the day
following the expiration date of a current agreement) if, on the date
of the survey, the provider meets all Federal health and safety
conditions of participation or level A requirements (for SNFs), and any
other requirements imposed by HCFA.
(b) All Federal requirements are not met on the date of the survey.
Except as provided in paragraph (c) of this section, if the
provider fails to meet any of the requirements specified in paragraph
(a) of this section, the agreement is effective on the earlier of the
following dates:
(1) The date on which the provider meets all requirements.
(2) The date on which the provider submits a correction plan
acceptable to HCFA or an approvable waiver request, or both.
(c) Community mental health center (CMHC). The effective date of a
provider agreement with a CMHC is determined as follows:
(1) Request for Medicare participation received before July 1,
1992.
(i) If all Federal requirements were met by October 1, 1991, the
agreement is effective October 1, 1991, or such later date as requested
by the CMHC.
(ii) If all Federal requirements were not met by October 1, 1991,
the agreement is effective on the date the CMHC meets all Federal
requirements.
(2) Request for Medicare participation received after June 30,
1992. The agreement is effective on the date the CMHC meets all Federal
requirements, but not before the date HCFA receives the application.
E. Part 498 is amended as follows:
PART 498--APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT
PARTICIPATION IN THE MEDICARE PROGRAM
1. The authority citation for part 498 is revised to read as
follows:
Authority: Secs. 205(a), 1102, 1861(aa), 1866, 1869(c), 1871,
and 1872 of the Social Security Act (42 U.S.C. 405(a), 1302,
1395x(aa), 1395cc, 1395ff(c), 1395hh, and 1395ii), unless otherwise
noted.
2. In Sec. 498.2, the introductory text is republished, the
definition for ``Prospective supplier'' is removed and definitions for
``Provider'' and ``Supplier'' are revised to read as follows:
Sec. 498.2 Definitions.
As used in this part--
* * * * *
Provider means a hospital, skilled nursing facility (SNF),
comprehensive outpatient rehabilitation facility (CORF), home health
agency (HHA), or hospice, that has in effect an agreement to
participate in Medicare; or a clinic, rehabilitation agency, or public
health agency that has in effect a similar agreement but only to
furnish outpatient physical therapy, occupational therapy, or
outpatient speech pathology services, or a community mental health
center (CMHC) that has in effect a similar agreement but only to
provide partial hospitalization services, and prospective provider
means any of the listed entities that seeks to participate in Medicare
as a provider.
Supplier means an independent laboratory, supplier of portable X-
ray services, rural health clinic (RHC), Federally qualified health
center (FQHC), ambulatory surgical center (ASC), organ procurement
organization (OPO), or end-stage renal disease (ESRD) treatment
facility that is approved by HCFA as meeting the conditions for
coverage of its services, and prospective supplier means any of the
listed entities that seeks to be approved for coverage of its services
under Medicare. (However, for purposes of the sanctions and penalties
that may be imposed by the OIG, the term supplier has the meaning
specified in Sec. 1001.2 of this title.)
(Catalog of Federal Domestic Assistance Program No. 93.774,
Medicare--Supplementary Medical Insurance Program)
Dated: September 15, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Approved: October 26, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-2680 Filed 2-10-94; 8:45 am]
BILLING CODE 4120-01-P
