insurance benefits for the month in which he is convicted or for any month thereafter, there shall not be taken into consideration:

(1) Any wages paid to the individual or to any other individual in the calendar quarter in which such conviction occurs or in any prior calendar quarter; and

(2) Any net earnings from self-employment derived by such individual or any other individual during the taxable year in which such conviction occurs or during any prior taxable year.

(b) If such individual is granted a pardon by the President of the United States, the additional penalty provided above shall not apply for any month beginning after the date on which the pardon is granted.

[31 F.R. 10122, July 27, 1966]

§ 405.191

Emergency services; finding that an emergency existed and/or has ceased.

(a) General. Payment to a nonparticipating hospital for emergency services (as defined in § 405.152(b)) can be made only for the period during which the emergency exists.

(b) Objective. The objective of paragraph (a) of this section is to limit reimbursement for emergency inpatient hospital services only to periods during which the patient's state of injury or disease is such that a health or lifeendangering emergency existed and continued to exist, requiring immediate care which could only be provided in a hospital.

(1) The finding that an emergency existed and/or has ceased will ordinarily be supported by medical evidence including the attending physician's supporting statement (see § 405.152 (a) (8)) and, when appropriate, information furnished by the hospital. However, a statement by the physician or hospital that an emergency existed, in the absence of sufficient medical information to establish the actual emergency, will not constitute sufficient evidence of the existence of an emergency.

(2) An emergency no longer exists when it becomes safe from a medical standpoint to move the individual to a participating hospital or other institution, or to discharge him.

(3) Existence of medical necessity for emergency services is based on the physician's assessment of the patient prior to admission to the hospital. Therefore, conditions developing after a nonemer

gent admission are not considered emergency services for purposes of this subparagraph.

(4) Death of the patient during hospitalization will not necessarily establish the existence of an emergency, as some chronically ill patients, while requiring long terminal hospitalization, are not in need of immediate hospitalization, so that care in a participating hospital can be planned. Similarly, lack of adequate care at home does not necessarily establish need for emergency services.

(5) Lack of transportation to a participating hospital does not constitute a reason for emergency hospital admission. unless there is also an immediate threat to the life and health of the patient. [34 F.R. 11208, July 3, 1969]

§ 405.192 Emergency services; finding of accessibility.

(a) General. Services, to be emergency services (as defined in § 405.152(b)), must be furnished by the most accessible hospital available and equipped to furnish such services.

(b) Objectives. The objective of the requirement in paragraph (a) of this section is to limit reimbursement for emergency inpatient hospital services provided by nonparticipating hospitals to situations where transport of the patient to a participating hospital would have been medically inadvisable, e.g.. the participating hospital would have taken longer to reach and the patient's condition necessitated immediate admission for hospital services; and for so long as that condition precluded the patient's discharge or removal to a participating hospital.

(1) In emergency situations, time is a crucial factor and the patient must ordinarily receive hospital care as soon as possible. Under such circumstances, all factors must be considered which bear on whether or not the required care could be provided sooner in the nonparticipating hospital than in a participating hospital in the general area. The determination must take account of such matters as relative distances of the participating and nonparticipating hospitals, the transportation facilities available to these hospitals, the quality of the roads to each hospital, the availability of beds at each hospital, and any other relevant factors. All of these factors are pertinent to a determination of whether a hospital is "the nearest,"

or "further away," or "closer to" the place where the emergency occurred.

(2) The considerations referred to in subparagraph (1) of this paragraph are generally applicable to rural areas, where hospitals are likely to be spaced far apart. In urban and suburban areas, where both participating and nonparticipating hospitals are similarly available, it will be presumed that the services could have been provided in a participating hospital. This presumption can be overcome only by clear and convincing evidence showing the medical or practical necessity in each individual case for taking the patient to a nonparticipating hospital instead of a similarly available participating hospital.

(3) There are some situations requiring prompt removal of a patient to a hospital but in which there was no immediate need, of the kind described in subparagraph (1) of this paragraph, to rush the patient to a hospital, i.e., his condition, while requiring prompt attention in a hospital, indicated there was some time available to get him to one. In such cases the services provided in a nonparticipating hospital are not covered as emergency inpatient hospital services if there was a participating hospital in the same general area but further away from the place where the emergency occurred, provided that professional judgment confirms that the additional time required to take the patient to the participating hospital would not have been hazardous to the patient.

(4) The determination whether the nonparticipating hospital which claims reimbursement is the most "accessible" hospital will be made on the basis of the considerations set forth in paragraphs (c) and (d) of this section; interpreted in accordance with the statement of objectives in this paragraph (b). The personal preference of a patient, or of his physician, or of members of his family, or others, in the selection of a hospital, will not be considered a factor in determining whether services were furnished by the most accessible hospital. Nor will the nonavailability of staff privileges to the attending physician in a participating hospital which is available and most accessible to the patient, or the location of previous medical records, be considered a factor in the determination of accessibility.

(c) Conditions under which the accessibility requirement will be met. Where an individual must be taken to a hospital immediately for required diagnosis or medical treatment, the accessibility requirement will be met, except as provided in paragraph (d) of this section, if it is established to the satisfaction of the Administration that:

(1) The nonparticipating hospital which furnished the emergency services is the nearest hospital to the point at which the emergency occurred (subject to the presumption contained in paragraph (b) (2) of this section); and, if there is a similarly available participating hospital, the evidence shows the medical or practical necessity for taking the patient to a nonparticipating hospital;

or

(2) One or both of the following reasons apply:

(i) No closer participating hospital has a bed available or will accept the individual; cr

(ii) The nonparticipating hospital is the nearest one equipped medically to deal with the type of emergency involved; or it is the nearest hospital which is equipped to handle the emergency which had a bed available when the emergency occurred.

(d) Conditions under which the accessibility requirement will not be met. The accessibility requirement will not be met

if:

(1) (i) The diagnosis in the emergency claim or other evidence indicates there was some time for getting the individual to a hospital, and no immediate need to rush him to one; and

(ii) There is a participating hospital in the area which is further away from the point at which the emergency occurred than the nonparticipating hospital, but is equipped to handle such an emergency; and

(iii) The additional time it would have required to take the individual to the participating hospital would not have been hazardous to the patient; or

(2) There is a participating hospital, equipped to handle the emergency with a bed available, closer to where the emergency occurred than the nonparticipating hospital in which the beneficiary received emergency services; and neither of the reasons described in paragraph (c) (2) of this section apply. [34 F.R. 11208, July 3, 1969]

Subpart B-Supplementary Medical Insurance Benefits

AUTHORITY: The provisions of this Subpart B issued under secs. 1102, 1831-1843, 1871, 49 Stat. 647, as amended, 79 Stat. 301-313; 79 Stat. 331; 42 U.S.C. 1302, 1395 et seq.

SOURCE: The provisions of this Subpart B appear at 31 F.R. 9580, July 14, 1966, unless otherwise noted.

§ 405.201 Supplementary medical insurance benefits; general.

Part B of title XVIII of the Act provides for a voluntary "supplementary medical insurance plan" available to most individuals age 65 and over. This supplementary medical insurance plan (which is financed by premiums paid by each individual who enrolls in the plan plus matching contributions from funds appropriated by the Federal Government) provides coverage against the costs of certain physicians' services, home health services (without any requirement of prior hospitalization), and other medical and health services in and out of medical institutions. The conditions for enrollment in the supplementary medical insurance plan, the types of benefits provided, amounts paid, and limitations and conditions with respect to payment are set out in this Subpart B.

§ 405.202 Enrollment; general.

To become entitled to supplementary medical insurance benefits, an individual must meet the requirements for enrollment (see § 405.205) and must enroll (see § 405.210) under the supplementary medical insurance plan during the enrollment period applicable in his case (see §§ 405.211 through 405.217).

§ 405.205 Supplementary medical insurance benefits; conditions for enrollment.

An individual who is age 65 or over is eligible to enroll in the supplementary medical insurance plan (unless excluded under § 405.206) if:

(a) He is entitled to hospital insurance benefits under title XVIII of the Act (see § 404.367 in Part 404 of this chapter); or

(b) He is a citizen and resident of the United States; or

(c) He is an alien lawfully admitted for permanent residence, who is a resi

dent of the United States and who has resided in the United States continuously during the 5 years immediately preceding the month in which he applies for enrollment.

§ 405.206 Supplementary medical insurance benefits; persons ineligible to enroll.

Notwithstanding the provisions specified in § 405.205, an individual is not eligible for enrollment for supplementary medical insurance benefits if he has been convicted of any offense under chapter 37 (relating to espionage and censorship) chapter 105 (relating to sabotage), or chapter 115 (relating to treason, sedition, and subversive activities) of title 18 of the United States Code, or under sections 4, 112, or 113 of the Internal Security Act of 1950, as amended (relating to conspiracies to establish dictatorships and conspiracies to commit espionage or sabotage).

§ 405.210 Enrollment procedures.

In order for an eligible individual (see § 405.205) to become enrolled under the supplementary medical insurance benefits plan, a written request for enrollment, signed by or on behalf of the enrollee, must be filed with the Administration during a period of enrollment open to such individual (see §§ 405.211 through 405.217).

§ 405.211

Enrollment periods; general.

An individual may enroll for supplementary medical insurance benefits only during an "enrollment period." There are two kinds of enrollment periods-the "initial enrollment period," which is based on the time when the individual first meets the eligibility requirements for enrollment, and the "general enrollment period" during which an individual who failed to enroll during his initial enrollment period or whose enrollment terminated may, with certain limitations, first enroll, or reenroll.

§ 405.212 Initial enrollment period.

(a) General. An individual's first opportunity to enroll for supplementary medical insurance benefits is called his "initial enrollment period." The beginning and ending dates of an individual's initial enrollment period are determined by the date on which he first meets the requirements for enrollment (see § 405.205).

(b) Individual eligible before March 1966. If an individual meets the requirements in § 405.205 before March 1966, his initial enrollment period begins on September 1, 1965, and ends on May 31, 1966, subject however to the provisions described in § 405.224 (relating to good cause for failure to enroll). (c) Individual first eligible after February 1966. If an individual first meets the conditions for eligibility in § 405.205 after February 1966, his initial enrollment period begins on the 1st day of the third month before the month in which he first meets such requirements and ends with the close of the last day of the third month following the month in which he first satisfies such requirements.

(d) First eligibility for enrollment; individual eligible solely because of entitlement to hospital insurance benefits. For purposes of determining the initial enrollment period of an individual who is eligible for enrollment solely because he is entitled to hospital insurance benefits (see § 405.205(a)), the individual is the first day on which he would be enconsidered as first meeting the requirements for eligibility for enrollment on titled to hospital insurance benefits upon filing application therefor whether or not he so filed.

§ 405.213 General enrollment periods.

There shall be a general enrollment period beginning on October 1 and ending on December 31 of each oddnumbered year beginning with 1967. Subject to the provisions of § 405.224 (relating to extension of the initial enrollment period for "good cause"), an Individual who fails to enroll for supplementary medical insurance benefits during his initial enrollment period may enroll only during a subsequent general enrollment period.

§ 405.214 Limitation on enrollment and

reenrollment.

(a) First enrollment. An individual who fails to enroll for supplementary medical insurance benefits during his nitial enrollment period may enroll in a general enrollment period provided that such enrollment occurs within 3 years after the close of his initial enrollment period. An individual who does not enoll for supplementary medical insurance benefits within the 3-year period after

the close of his initial enrollment period, is precluded from such enrollment.

Example 1: An individual first meets the requirements for enrollment in August 1966. He does not enroll during his initial enrollment period-May through November 1966. If he wishes to be covered in the supplementary insurance plan, he must enroll during the general enrollment period-October through December 1967 or during the first 2 months of the 1969 general enrollment1.e., October 1969 and November 1969. Even though the 1969 general enrollment period runs through December of 1969, the individual cannot enroll after November 1969, the end of the 3-year period after the close of his initial enrollment period.

Example 2: An individual first meets the requirements for enrollment in June of 1968 but fails to enroll during his initial enrollment period-March through September 1968. If he later wishes to enroll, he must do so within the 3-month period October through December 1969, the only general enrollment period falling within the 3-year period after the close of his initial enrollment period.

(b) Second enrollment. An individual whose enrollment under the supplementary medical insurance plan has terminated (see § 405.223) may reenroll under the supplementary medical insurance plan provided that such reenrollment occurs within a general enrollment period which begins within 3 years after the effective date of the termination of his prior enrollment.

Example 1: An individual notified the Administration in writing during the general enrollment period beginning October 1, 1969, that he no longer wished to participate in the supplementary medical insurance plan and had his enrollment terminated on December 31, 1969. If he wishes to reenroll under the supplementary insurance plan, he must do SO within the period October through December 1971, the only general enrollment period beginning within 3 years after the termination date of his prior enrollment.

Example 2: An individual's enrollment terminated on October 31, 1968, for nonpayment of premiums. If he wishes to reenroll under the supplementary medical insurance plan, he must do so within the general enrollment periods of October through December 1969, or October through December 1971, the two general enrollment periods beginning within 3 years after the termination date of his prior enrollment.

(c) Limitation on number of enrollments. No one may enroll under the supplementary medical insurance plan more than twice.

§ 405.217 Enrollment by a State of individuals receiving money payments under public assistance program. (a) Subject to the provisions of paragraph (c) of this section, the Secretary shall enter into an agreement with any State which so requests before 1968, pursuant to which all eligible individuals in either of the coverage groups described in paragraph (b) of this section (as specified in the agreement) will be enrolled under the supplementary medical insurance benefits plan.

(b) An agreement entered into with any State pursuant to paragraph (a) of this section shall be applicable to either of the following coverage groups:

(1) Individuals receiving money payments under the plan of such State approved under title I or title XVI of the Act; or

(2) All individuals receiving money payments under any of the plans of such State approved under titles I, IV, X, XIV, and XVI of the Act.

(c) Notwithstanding paragraph (b) of this section, an individual may not be a member of a coverage group for any month in which he is entitled to monthly benefits under title II of the Social Security Act or entitled to receive an annuity or pension under the Railroad Retirement Act of 1937 (without regard to the retroactivity of such entitlement) unless the State so requests before 1968 and the agreement provides, or is modified to provide, that such individual shall be a member of a coverage group as discussed in paragraph (b) of this section. No individual shall be a member of a coverage group after his coverage period attributable to this agreement has ended, if such coverage period ended after 1967.

(d) For purposes of this section, an individual is treated as an "eligible individual" only if he meets the requirements set forth in § 405.205 on the date an agreement covering him is entered into under paragraph (a) of this section (or in the case of Social Security Act or Railroad Retirement Act beneficiaries covered by virtue of a modification, as of the date the modification is entered into) or he meets such requirements at any time after such date and before 1968.

(e) For purposes of this section, an individual is treated as receiving money payments described in paragraph (b) of this section if he receives such payments for the month in which the agreement is entered into (or in the case of Social

Security Act or Railroad Retirement Act beneficiaries covered by virtue of a modification, for the month the modification is entered into) or for any month occurring thereafter and before 1968.

§ 405.220 Coverage period; general.

Payment is made under the supplementary medical insurance plan only for covered expenses incurred during an individual's "coverage period." An individual's coverage period begins and ends as described in §§ 405.221 through 405.223.

§ 405.221 Coverage period; beginning date.

An individual's "coverage period" can begin no earlier than July 1, 1966, and begins on a day as determined in accordance with this section (or in the case of an individual enrolled pursuant to a State agreement, in accordance with the provisions of § 405.222):

(a) Enrollment during initial enrollment period; first eligibility before March 1966. (1) The coverage period of an individual who first meets the eligibility requirements for enrollment (see § 405.205) prior to March 1966, and who enrolls during his initial enrollment period of September 1965 through May 1966, begins on July 1, 1966.

(2) The coverage period of an individual who first meets the eligibility requirements for enrollment (see § 405.205) prior to March 1966, who fails to enroll prior to June 1966, but who is authorized to enroll at a subsequent time not later than September 30, 1966, under the "good cause" provisions described in § 405.224, begins on the first day of the sixth month after the month in which he so enrolls.

(b) Enrollment during initial enrollment period; first eligibility in March 1966. (1) The coverage period of an individual who first meets the eligibility requirements for enrollment during the month of March 1966, and who enrolls before June 1966, begins on July 1, 1966.

(2) The coverage period of an individual who first meets the eligibility requirements for enrollment during March 1966, and who enrolls during the month of June 1966, begins on September 1, 1966.

(c) Enrollment during initial enrollment period; first eligibility after March 1966. The coverage period of an individual who first meets the eligibility requirements for enrollment after March