C.F.R.
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Title 42
» CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES; PAYMENT FOR ACUTE KIDNEY INJURY DIALYSIS › Subpart J—Prospective Payment for Skilled Nursing Facili…
(a) Method of payment. Under the prospective payment system, SNFs receive a per diem payment of a predetermined rate for inpatient services furnished to Medicare beneficiaries. The per diem payments are made on the basis of the Federal payment rate described in § 413.337 and, during a transition period, on the basis of a blend of the Federal rate and the facility-specific rate described in § 413.340. These per diem payment rates are determined according to the methodology described in §§ 413.337 and 413.340.
(b) Payment in full. (1) The payment rates represent payment in full (subject to applicable coinsurance as described in subpart G of part 409 of this chapter) for all costs (routine, ancillary, and capital-related) associated with furnishing inpatient SNF services to Medicare beneficiaries other than costs associated with approved educational activities as described in § 413.85.
(2) In addition to the Federal per diem payment amounts, SNFs receive payment for bad debts of Medicare beneficiaries, as specified in § 413.89 of this part.
[63 FR 26309, May 12, 1998, as amended at 73 FR 46440, Aug. 8, 2008]
Notes of Decisions
Angela Ruckh v. Salus Rehab., LLC, 963 F.3d 1089 (11th Cir. 2020).
“§ 1395yy; 42 C.F.R. § 413.335 . Medicare bases its payment amount in part on information provided to it by SNFs.”
Fal-Meridian, Inc. v. U.S. Dep't of Health, 604 F.3d 445 (7th Cir. 2010).
“§ 1395yy; 42 C.F.R. § 413.335 ; Medicare Payment Advisory Comm’n, “Medicare Payment Basics: Skilled Nursing Facility Services Payment System” (Oet.”
United States ex rel. Crockett v. Complete Fitness Rehab. (6th Cir. 2018).
· cites it 2× “See 42 C.F.R. § 413.335 (a). This per diem rate is determined by the level of a patient’s medical needs, as periodically determined by a licensed clinical professional during the patient’s stay at the facility.”
Delia Bell v. Karl E. Cross (11th Cir. 2021).
“§ 1395yy; 42 C.F.R. § 413.335 . The per diem rate at which Medicare reimburses SNFs is re- lated to the patient’s Resource Utilization Group (RUG) score, which quantifies the patient’s need for therapy.”
Bell v. Cross (M.D. Fla. 2019).
“335 (a) (providing that “[u]nder the prospective payment system, [skilled nursing facilities] receive a per diem payment of a predetermined rate for inpatient services furnished to Medicare beneficiaries”). In sum, the allegations in Count I state an FCA claim, and this part of…”
Bell v. Cross (M.D. Fla. 2021).
“177-2 ff 6, 8); 42 C.F.R. § 413.335 (a). The payment rate, as well as service frequency, variety, and duration devoted to a patient, are determined by the patient’s RUG score.”
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