C.F.R. » 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 A—Introduction and General Rules

42 C.F.R. § 413.5

Cost reimbursement: General

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(a) In formulating methods for making fair and equitable reimbursement for services rendered beneficiaries of the program, payment is to be made on the basis of current costs of the individual provider, rather than costs of a past period or a fixed negotiated rate. All necessary and proper expenses of an institution in the production of services, including normal standby costs, are recognized. Furthermore, the share of the total institutional cost that is borne by the program is related to the care furnished beneficiaries so that no part of their cost would need to be borne by other patients. Conversely, costs attributable to other patients of the institution are not to be borne by the program. Thus, the application of this approach, with appropriate accounting support, will result in meeting actual costs of services to beneficiaries as such costs vary from institution to institution. However, payments to providers of services for services furnished Medicare beneficiaries are subject to the provisions of §§ 413.13 and 413.30.

(b) Putting these several points together, certain tests have been evolved for the principles of reimbursement and certain goals have been established that they should be designed to accomplish. In general terms, these are the tests or objectives:

(1) That the methods of reimbursement should result in current payment so that institutions will not be disadvantaged, as they sometimes are under other arrangements, by having to put up money for the purchase of goods and services well before they receive reimbursement.

(2) That, in addition to current payment, there should be retroactive adjustment so that increases in costs are taken fully into account as they actually occurred, not just prospectively.

(3) That there be a division of the allowable costs between the beneficiaries of this program and the other patients of the provider that takes account of the actual use of services by the beneficiaries of this program and that is fair to each provider individually.

(4) That there be sufficient flexibility in the methods of reimbursement to be used, particularly at the beginning of the program, to take account of the great differences in the present state of development of recordkeeping.

(5) That the principles should result in the equitable treatment of both nonprofit organizations and profit-making organizations.

(6) That there should be a recognition of the need of hospitals and other providers to keep pace with growing needs and to make improvements.

(c) As formulated herein, the principles given recognition to such factors as depreciation, interest, bad debts, educational costs, compensation of owners, and an allowance for a reasonable return on equity capital (in the case of certain proprietary providers). With respect to allowable costs some items of inclusion and exclusion are:

(1) An appropriate part of the net cost of approved educational activities will be included.

(2) Costs incurred for research purposes, over and above usual patient care, will not be included.

(3) [Reserved]

(4) The value of services provided by nonpaid workers, as members of an organization (including services of members of religious orders) having an agreement with the provider to furnish such services, is includable in the amount that would be paid others for similar work.

(5) Discounts and allowances received on the purchase of goods or services are reductions of the cost to which they relate.

(6) Bad debts growing out of the failure of a beneficiary to pay the deductible, or the coinsurance, will be reimbursed (after bona fide efforts at collection).

(7) Charity and courtesy allowances are not includable, although “fringe benefit” allowances for employees under a formal plan will be includable as part of their compensation.

(8) A reasonable allowance of compensation for the services of owners in profitmaking organizations will be allowed providing their services are actually performed in a necessary function.

(9) Reasonable cost of physicians' direct medical and surgical services (including supervision of interns and residents in the care of individual patients) furnished in a teaching hospital may be reimbursed as a provider cost (as described in § 415.162 of this chapter) if elected as provided for in § 415.160 of this chapter.

(d) In developing these principles of reimbursement for the Medicare program, all of the considerations inherent in allowances for depreciation were studied. The principles, as presented, provide options to meet varied situations. Depreciation will essentially be on an historical cost basis but since many institutions do not have adequate records of old assets, the principles provide an optional allowance in lieu of such depreciation for assets acquired before 1966. For assets acquired after 1965, the historical cost basis must be used. All assets actually in use for production of services for Medicare beneficiaries will be recognized even though they may have been fully or partially depreciated for other purposes. Assets financed with public funds may be depreciated. Although funding of depreciation is not required, there is an incentive for it since income from funded depreciation is not considered as an offset which must be taken to reduce the interest expense that is allowable as a program cost.

(e) A return on the equity capital of proprietary facilities, as described in § 413.157, is an allowance in addition to the reasonable cost of covered services furnished to beneficiaries.

(f) Renal dialysis items and services furnished under the ESRD provision are reimbursed and reported under §§ 413.170 and 413.174 respectively. For special rules concerning health maintenance organizations (HMOs), and providers of services and other health care facilities that are owned or operated by an HMO, or related to an HMO by common ownership or control, see §§ 417.242(b)(14) and 417.250(c) of this chapter.

[51 FR 34793, Sept. 30, 1986; 51 FR 37398, Oct. 22, 1986, as amended at 52 FR 21225, June 4, 1987; 52 FR 23398, June 19, 1987; 57 FR 39829, Sept. 1, 1992; 60 FR 63189, Dec. 8, 1995; 61 FR 63748, Dec. 2, 1996]
Notes of Decisions
Cited in 31 cases (3 in the last 5 years), 1987–2023 · leading case: Shalala v. Guernsey Memorial Hospital
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Shalala v. Guernsey Memorial Hospital (1995) scotus · cites it 2× “The Secretary must calculate how much of a provider's total allowable costs are *98 attributable to Medicare services, see 42 CFR §§ 413.5 (a), 413.9(a), and (c)(3) (1994), which entails calculating what proportion of the provider's services were delivered to Medicare patients,…”
Fischer v. United States (2000) scotus · cites it 2× “42 CFR § 413.5 (b)(1) (1999) (requiring reimbursement method to "result in current payment so that institutions will not be disadvantaged, as they sometimes are under other arrangements, by having to put up money for the purchase of goods and services well before they receive…”
St. Luke's Methodist Hospital v. Thompson (2001) iand · cites it 2× “This “no cross-subsidization” principle is reiterated in 42 C.F.R. § 413.5 (a) and (b)(3), and 42 C.”
Robert F. Kennedy Medical Center v. Belshe (1996) cal · cites it 2× “) The statute, however, did not contain any provision for an audit of a provider's expenditures under the Medi-Cal program.”
Visiting Nurse Ass'n of Brooklyn v. Thompson (2004) nyed · cites it 2× “See also, 42 C.F.R. § 413.5 (a), 42 C.F.R. § 413.5 (b)(3), 42 C.”
Abraham Lincoln Memorial Hospital v. Sebelius (2012) ca7 “42 C.F.R. §§ 413.5 (c), 413.98. In determining allowable costs, the Secretary should not look at costs in a vacuum, but must look at the totality of the circumstances.”
National Medical Enterprises, Inc. v. Bowen (1987) cacd · cites it 5× “The Board drew further support for its view that ROE was a current cost from 42 C.F.R. § 413.5 (a) and (b)(2). Id. 42 C.”
Congress of California Seniors v. Catholic Healthcare West (2001) calctapp · cites it 2× “” ( 42 C.F.R. § 413.5 (b)(1) (1999).) 5 The objective is that costs with respect to individuals covered by Medicare will not be borne by those not covered, while the costs for individuals not covered will not be borne by Medicare.”
Select Specialty Hospital—Bloomington, Inc. v. Burwell (2014) cadc “” 42 C.F.R. § 413.5 (a) (explaining the reasonable-cost reimbursement scheme); 52 Fed.”
St. Michael's Medical Center v. Sebelius (2009) dcd “Additional Claims Plaintiffs also contend that the Secretary’s exclusion of reclassified hospitals from the wage index calculations in FY 2000 and 2001(1) violated 42 C.F.R. § 413.5 (b)(3); (2) was arbitrary and capricious in violation of 5 U.”
El Paso Healthcare System, Ltd. v. Molina Healthcare of New Mexico, Inc. (2010) txwd “See generally 42 C.F.R. § 413.5 (“[P]ayment is to be made on the basis of current costs of the individual provider, rather than costs of a past period or a fixed negotiated rate.”
Guernsey Memorial Hospital v. Sullivan (1992) ohsd · cites it 2× “The general principles for cost reimbursement are set forth in 42 C.F.R. § 413.5 , which provides that “[a]ll necessary and proper expenses of an institution in the production of services .”
Show all 31 citing cases →
— 42 C.F.R. § 413.5(b)(2) — 1 case
National Medical Enterprises, Inc. v. Bowen (1987) cacd “The Board drew further support for its view that ROE was a current cost from 42 C.F.R. § 413.5 (a) and (b)(2). Id. 42 C.”
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