furnished after December 31, 1967, during such spell of illness):

(2) An additional 60 days-less one day for each day of inpatient hospital services in excess of 90 days received during any preceding spell of illness. The individual has the option of electing by a signed statement not to have payment made for such additional days of inpatient hospital services furnished him after he has received benefits for 90 days of such services in a spell of illness. Payment may be made for such additional days unless the provider furnishing such services has on record the individual's signed election not to have payment made for such services.

(b) Deductible and coinsurance amounts. Payments for inpatient hospital services furnished during any spell of illness is reduced by the amount of the applicable deductibles (see §§ 405.113 and 405.114) and, in addition, by any applicable coinsurance amount (see § 405.115).

(c) Benefit limitation for spell of illness. (1) No payment under this section for inpatient hospital services furnished an individual during a spell of illness which ends on or before December 31, 1967, may be made for any such services furnished to him after the 90th day such services have been furnished to him during such spell of illness (see § 405.161 for exception); and

(2) No payment under this section for inpatient hospital services furnished an individual during a spell of illness which begins, or is continuing after December 31, 1967, may be made for any such services furnished to him after the 150th day (less 1 day for each day of inpatient hospital services in excess of 90 days received during any preceding spell of illness) that such services have been furnished to him during such spell of illness (see § 405.161 for exception).

(d) Lifetime maximum on inpatient psychiatric hospital services. Notwithstanding the preceding provisions of this section, no payment for inpatient psychiatric hospital services (see Subpart J of this part) may be made for any such services furnished an individual after the 190th day such services have been furnished to him during his lifetime (see § 405.161 for exception). [34 F.R. 11202. July 3, 1969]

§ 405.111 Inpatient hospital services; benefit limitation during first spell of illness—inpatient of participating tuberculosis or psychiatric hospital. Subject to the provision that the benefit limitation described in this section shall not apply with respect to inpatient tuberculosis hospital services furnished to an individual after December 31, 1967:

(a) Date of entitlement on or after January 1, 1968; inpatient of psychiatric hospital on first day of entitlement. If an individual is an inpatient of a participating psychiatric hospital on the first day for which he is entitled to hospital insurance benefits (see § 405.103) and becomes entitled to such benefits on or after January 1, 1968, the days (not necessarily consecutive) on which he was an inpatient of a psychiatric hospital in the 150-day period immediately before such first day are deducted from the 150 days of inpatient hospital services for which he is otherwise entitled to have payment made during his first spell of illness, where such services are furnished to him in a psychiatric hospital or in a hospital (other than a tuberculosis hospital) in which the individual was an inpatient primarily for the diagnosis or treatment of mental illness. Thus, the benefit limitation described in this paragraph will not apply to inpatient hospital services furnished in a tuberculosis hospital or to such services furnished in a hospital (other than a psychiatric hospital) that are not primarily for the diagnosis or treatment of mental illness.

(b) (1) Date of entitlement prior to 1968; inpatient of psychiatric or tuberculosis hospital on first day of entitlement. Subject to the provisions of the succeeding subparagraphs of this paragraph, if an individual was an inpatient of a participating tuberculosis or psychiatric hospital on the first day for which he is entitled to hospital insurance benefits and was entitled to such benefits before January 1, 1968, the days (not necessarily consecutive) on which he was an inpatient of a psychiatric or tuberculosis hospital in the 90-day period immediately before such first day are deducted from the 90 days of inpatient hospital services for which he is otherwise entitled to have payment made during his first spell of illness.

(2) First spell of illness is continuing after December 31, 1967; inpatient of participating tuberculosis hospital upon

entitlement. An individual who after December 31, 1967, is still in his first spell of illness and was subject to a reduction in benefit days prior to 1968 under subparagraph (1) of this paragraph because he was in a participating tuberculosis hospital at the time of entitlement to hospital insurance benefits will have those days restored for any inpatient hospital services furnished to him after December 31, 1967. The benefit limitation will not apply to services furnished after 1967, to an individual who at the time of entitlement was an inpatient of a participating tuberculosis hospital. Thus, such an individual is eligible on January 1, 1968, for up to 150 days of any inpatient hospital services in his first spell of illness.

(3) First spell of illness is continuing after December 31, 1967; inpatient of a psychiatric hospital upon entitlement. An individual who after December 31, 1967, is still in his first spell of illness and was subject to a reduction in benefit days prior to 1968 under subparagraph (1) of this paragraph because he was in a participating psychiatric hospital at the time of entitlement to hospital insurance benefits may be entitled to additional benefit days for inpatient hospital services furnished on or after January 1, 1968:

(i) On January 1, 1968, such individual becomes eligible for 60 additional days of inpatient hospital services (see § 405.110). Before these days can be used to pay for inpatient hospital services furnished to such individual by a psychiatric hospital, or for such services furnished by a hospital (other than a psychiatric or tuberculosis hospital) which are primarily for the diagnosis or treatment of mental illness, those days on which he was an inpatient of a psychiatric hospital from the 91st to the 150th day of the 150-day period preceding the first day for which he became entitled to hospital insurance benefits will be subtracted from the 60 additional days available for use in such first spell of illness. For inpatient hospital services furnished prior to 1968, the number of benefit days available to such individual during his first spell of illness was determined on the basis of the 90-day period immediately preceding the first day of entitlement to hospital insurance benefits in accordance with subparagraph (1) of this paragraph. Payment for inpatient hospital services furnished to the individual on or after January 1,

1968, by a hospital (other than a tuberculosis hospital) for such services which are primarily for the treatment or diagnosis of mental illness, or for such serv-| ices furnished by a psychiatric hospital. will be made for any days still payable under such prior determination and then for any of the 60 additional days available as determined in accordance with the provisions of this paragraph. (However, a new determination for the 90-day preentitlement period will be required if tuberculosis hospital days were included in the prior determination. See subdivision (iii) of this subparagraph);

(ii) Payment for inpatient hospital services furnished on or after January 1, 1968, to such individual by a hospital (other than a psychiatric hospital) for such services which are primarily for the diagnosis or treatment of a condition other than mental illness, or for such services furnished by a tuberculosis hospital in his first spell of illness, may be made for any unused benefit days: Plus the number of days for which the beneficiary's eligibility was previously reduced; plus, the 60 additional days avail. able under § 405.110; and

(iii) Days spent by such individual in a tuberculosis hospital in the preentitlement period do not count as reduction days for inpatient hospital services received after 1967, and such days are restored. This applies not only for an indi vidual who was in a tuberculosis hospital when he became entitled but also for an individual who was in a psychiatric hospital at the time of entitlement after having spent some of his preentitlement days in a tuberculosis hospital.

(c) Charging deduction days. In reducing the number of days for which an individual is entitled to have payment made for inpatient hospital services, days subject to deduction (as determined in accordance with the provisions of paragraphs (a) and (b) of this section) are charged in the following order:

(1) Those days after the 90th and before the 150th days for which such individual is entitled to have payment made during such spell of illness;

(2) Those days after the 60th day and before the 91st day for which such individual is entitled to have payment made for such services during such spell of illness; and

(3) Those days before the 61st day for which such individual is entitled to have payment made for such services during such spell of illness.

(d) Limitation on application of deduction. Notwithstanding the preceding provisions of this section, days preceding the first day for which an individual is entitled to hospital insurance benefits (see § 405.103), are not counted in determining the 190-day lifetime limit on inpatient psychiatric hospital services (see § 405.110 (d)), and are not counted in determining the first day for which the coinsurance amount is deducted from payment for inpatient hospital services (see § 405.115).

EXAMPLE 1: B is an inpatient of a participating psychiatric hospital on July 1, 1966, the first day for which he is entitled to hospital insurance benefits, and has been an inpatient of such hospital for the 2 years immediately preceding July 1, 1966. If B's first spell of illness ends on or before December 31, 1967, no payment will be made for inpatient hospital services furnished to B during that spell of illness. However, if B's first spell of illness is continuing after December 31, 1967, he will be eligible, with respect to services furnished after such date, to have payment made for up to 150 days of inpatient hospital services during such spell of illness if the services are furnished to him by a tuberculosis hospital (see § 405.111(b)) or, if furnished to him by a hospital other than a psychiatric or tuberculosis hospital, are not primarily for the diagnosis or treatment of a mental illness.

EXAMPLE 2: C entered a participating tuberculosis hospital on August 12, 1966, and is still an inpatient of such hospital 50 days later on October 1, 1966, the first day for which he is entitled to hospital insurance benefits. Payment may be made for up to 40 days of inpatient hospital services since C had been an inpatient of the tuberculosis hospital for 50 days preceding the first day for which he was entitled to hospital insurance benefits. However, the 50 days preceding October 1, 1966, is not counted in determining the 60 days of coverage and, therefore, the coinsurance amount (see § 405.115) is not applicable with respect to any payment for the 40 days of services for which C is entitled to have payment made on his behalf with respect to services furnished before 1968. If C's first spell of illness is continuing after December 31, 1967, the 50 days subject to deduction will be restored to him and he will be eligible, with respect to services furnished after such date, to have payment made for up to 110 additional days of inpatient hospital services during such spell of illness (i.e., the restored 50 days plus the 60 additional days of entitlement-see § 405.110(a)). The coinsurance amounts discussed in § 405.115 would, of course, be applicable with respect to such services furnished after the 60th day in this spell of illness (see § 405.111(b)).

EXAMPLE 3: D is a patient of an institution that is not a qualified psychiatric hos

pital on August 1, 1966, the first day for which he is entitled to hospital insurance benefits, and has been a patient of the nonqualifying hospital for the 1 year preceding August 1, 1966. Several days later D is transferred to a participating psychiatric hospital. Payment may be made (with respect to services furnished before 1968) for up to 90 days of inpatient hospital services after such transfer since inpatient hospital services received in a nonqualifying hospital in the period preceding entitlement are not considered for the purposes of determining the spell of illness limitation. If D's first spell of illness is continuing after December 31, 1967, he will be eligible, with respect to services furnished after such date, to have payment made for an additional 60 days of inpatient hospital services (including inpatient psychiatric hospital services) during such spell of illness (see § 405.110).

[34 F.R. 11202, July 3, 1969]

§ 405.112 Inpatient hospital services; services considered for purposes of benefit limitations.

(a) For purposes of determining the 90-day or 150-day benefit limitation described in § 405.110 (c), or § 405.111, or the 190-day benefit limitation described in § 405.110 (d), inpatient hospital services are taken into account only if one or more of the following conditions apply to such services:

(1) Payment is made with respect to such services;

(2) Payment would be made for such services except for failure to comply with the request and certification requirements described in § 405.152 or § 405.160;

or

(3) Payment cannot be made for such services because of the deductible or coinsurance requirements described in §§ 405.113 and 405.115.

(b) Notwithstanding the provisions of paragraph (a) of this section, days after the 90th day on which an individual is furnished inpatient hospital services during a spell of illness are not taken into account in determining the benefit limitation discussed in this section, if the individual has elected not to have payment made for such days (see § 405.110 (a) (2)) or the daily charge for such days is equal to or less than the applicable coinsurance amount (see § 405.115(a) (2)). [34 F.R. 11203, July 3, 1969]

§ 405.113 Inpatient hospital services;

deductible.

(a) Spell of illness beginning prior to 1969. The amount payable for inpatient hospital services (see §§ 405.150, 405.151,

and 405.158) furnished to an individual during any spell of illness beginning prior to 1969 is reduced (but not below zero) by an amount equal to the lesser of:

(1) $40; or

(2) The charges imposed with respect to such services or the customary charges for such services, whichever is greater.

(b) Spell of illness beginning after 1968. Between July 1 and October 1 of 1968, and of each year thereafter, the Secretary shall determine the amount of the inpatient hospital deductible which shall be applicable in the case of any spell of illness beginning during the succeeding calendar year.

[34 F.R. 11203, July 3, 1969]

§ 405.114

Inpatient hospital services; whole blood cost deductible.

Where all or part of the first 3 pints of whole blood furnished an individual by a provider of services during a spell of illness is furnished him as part of inpatient hospital services, the amount payable for such services is reduced by the cost of the first 3 pints of whole blood furnished him as part of such services during that spell of illness.

EXAMPLE: During the same spell of illness, B receives the following services: inpatient hospital service in hospital X from July 1 to July 10, 1967: posthospital extended care services in an extended care facility from July 15 to July 25, 1967: inpatient hospital services in hospital Y from August 15 to August 25, 1967. During this spell of illness, B is furnished 6 pints of whole blood; 2 pints in hospital X, 2 pints in the extended care facility, and 2 pints in hospital Y. The whole blood deductible is applicable to the cost of the 2 pints of whole blood furnished in hospital X, and to the cost of 1 pint furnished in the extended care facility, since these are the first 3 pints of whole blood furnished B by providers of services during the spell of illness. It is not applicable to the cost of any of the whole blood furnished in hospital Y.

[31 F.R. 10118, July 27, 1966]

§ 405.115 Inpatient hospital services;

coinsurance amount.

(a) In any case in which an individual is furnished inpatient hospital services for more than 60 days during a spell of illness beginning before 1969, the amount payable (see §§ 405.150, 405.151, and 405.158), for the inpatient hospital services furnished after such 60th day during such spell of illness, is reduced by a coinsurance amount equal to:

(1) $10 for each day (or the actual charge when charges are less than $10

a day), after the 60th day and before the 91st day, on which he is furnished such services; plus (with respect to such services furnished after December 1967, during such spell of illness):

(2) $20 for each day after the 90th day and before the 151st day on which he is furnished such services.

(b) Since the inpatient hospital services coinsurance amount is set by law at one-fourth (for days after the 60th day and before the 91st day) and one-half (for entitlement days after the 90th day) of the inpatient hospital services deductible, the coinsurance amount applicable for spells of illness beginning after 1968 will reflect any adjustment made in the deductible (see § 405.113(b)).

[34 F.R. 11203, July 3, 1969]

§ 405.116 Inpatient hospital services; defined.

(a) Included services. Subject to the conditions, limitations, and exceptions in the succeeding paragraphs of this section, the term "inpatient hospital services" means the following items and services furnished by a qualified hospital, except as provided in paragraph (e) of this section (including a psychiatric hospital or a tuberculosis hospital) to an inpatient of such hospital:

(1) Bed and board;

(2) Nursing services and other related services;

(3) Use of hospital facilities; (4) Medical social services; (5) Drugs, biologicals, supplies, appliances and equipment;

(6) Certain other diagnostic or therapeutic items or services; and

(7) Medical or surgical services provided by certain interns or residents-intraining.

(b) Bed and board. The reasonable costs are payable in full for hospital room and board furnished an individual in accommodations containing from two to four beds, or in hospitals in which all accommodations are on a ward basis and charges are not related to the number of beds in a room. The reasonable cost of private accommodations is covered in full only where their use is medically indicated, ordinarily only when a patient's condition requires him to be isolated or when an individual (in need of immediate inpatient hospital care but not requiring isolation) is admitted to a hospital which has no semiprivate or ward accommodations, or at a time when such accommodations are occupied.

The reasonable cost of private accommodations will be paid in such cases until the individual's condition does not require him to be isolated or, in the case of the individual not requiring isolation, semiprivate accommodations are available. Where private accommodations are furnished for a patient's comfort, the amount payable under this Subpart A may not exceed the reasonable cost of accommodations containing from two to four beds. Where accommodations less expensive than available accommodations containing from two to four beds are furnished a patient and the use of these accommodations was neither at the request of the patient nor for a reason consistent with the purposes of the Act, the amount payable for bed and board is whichever is less, the reasonable cost of such accommodations, or the reasonable cost of two to four bed accommodations minus the difference between the customary charges for such accommodations and the customary charges for the accommodations furnished.

(c) Nursing services and other related medical services; medical social services; use of hospital facilities. Nursing services and other related services, use of hospital facilities, and medical social services, are considered as inpatient hospital services only if ordinarily furnished by the hospital for the care and treatment of inpatients. The services of a private-duty nurse or other private-duty attendant are excluded from the definition of inpatient hospital services.

(d) (1) Drugs and biologicals. Drugs and biologicals are included as inpatient hospital services only if they:

(i) Represent a cost to the hospital in rendering such services;

(ii) Are furnished to an inpatient for use in the hospital or, with respect to a limited supply required until the patient can obtain a continuing supply, are deemed medically necessary to permit or facilitate the patient's departure from the hospital; and

(iii) Are ordinarily furnished by such hospital for the care and treatment of inpatients.

(2) Supplies, appliances, and equipment. Supplies, appliances, and equipment are included as inpatient hospital services only:

(i) If ordinarily furnished by such hospital for the care and treatment of inpatients, and;

(ii) If furnished to an inpatient for use in the hospital, except in the case of

a temporary or disposable item provided to an inpatient for use beyond his hospital stay which is medically necessary to permit or facilitate the patient's departure from the hospital and which is required until such time as the patient can obtain a continuing supply, or in cases where it would be unreasonable or impossible from a medical standpoint to discontinue the patient's use of the item at the time of termination of his stay as an inpatient. (For example, tracheostomy or draining tubes, or cardiac valves and cardiac pacemakers.)

(e) Diagnostic or therapeutic items or services. Diagnostic or therapeutic items or services other than those provided for in paragraphs (c), (d), and (f) of this section, are considered as inpatient hospital services if furnished by the hospital, or by others under arrangements made by the hospital under which the billing for such services is made through such hospital and if such services are of a kind ordinarily furnished to inpatients either by such hospital or by others under such arrangements.

(f) Medical or surgical services provided by a physician, intern, resident, or resident-in-training. Medical or surgical services provided in a hospital by a physician or by a resident or intern, are excluded from the definition of "inpatient hospital services" unless such services are provided by an intern or resident-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association; or in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association; or in the case of a hospital or osteopathic hospital, by an intern or resident-in-training in the field of dentistry under a teaching program approved by the Council on Dental Education of the American Dental Association.

[31 F.R. 10118, July 27, 1966, as amended at 34 F.R. 11204, July 3, 1969]

§ 405.120 Posthospital extended services; scope of benefits.

care

(a) Benefits and conditions for entitlement. (1) An individual who meets the requirements described in § 405.102, is eligible to have payment made on his behalf to a participating extended care facility (see § 405.150) for up to 100 days of extended care services (§ 405.124) furnished to him in a spell of illness if