Page 126 - Medicare Benefit Policy Manual

individuals with intellectual disabilities (ICF/IID)). However, an institution may not be
considered a beneficiary’s home if it:

• Meets at least the basic requirement (see §1861(e)(1) of the Social Security Act
(the Act)) in the definition of a hospital, i.e., it is primarily engaged in providing
by or under the supervision of physicians, to inpatients, diagnostic and therapeutic
services for medical diagnosis, treatment, and care of injured, disabled, and sick
persons, or rehabilitation services for the rehabilitation of injured, disabled, or
sick persons; or

• Meets at least the basic requirement (see §1819(a)(1) of the Act) in the definition
of a skilled nursing facility, i.e., it is primarily engaged in providing to inpatients
skilled nursing care and related services for patients who require medical or
nursing care, or rehabilitation services for the rehabilitation of injured, disabled,
or sick persons.

Thus, if an individual is a patient in an institution or distinct part of an institution which
provides the services described in the bullets above, the individual is not entitled to have
separate Part B payment made for rental or purchase of DME. This is because such an
institution may not be considered the individual’s home (see §§1861(s)(6) and 1861(n) of
the Act, the implementing regulations at 42 CFR 410.38(b), and §2160B in the State
Operations Manual (SOM, Pub. 100-07), Chapter 2).

As indicated in §2164 of the SOM, Chapter 2, all hospitals and SNFs that are Medicare-
certified are automatically considered to meet the basic requirement described in the
applicable bullet above by reason of the Medicare certification itself. Moreover, even an
institution (or portion of an institution) that is not certified for Medicare is precluded
from being considered a patient’s home in this context if it meets either of these basic
requirements. See §2166 of the SOM, Chapter 2, for the administrative criteria used in
determining whether the basic requirement in the “SNF” definition is met by a nursing
home that is not Medicare-certified (including the non-Medicare portion of an institution
that also contains a Medicare-certified distinct part SNF).

If the patient is at home for part of a month and, for part of the same month is in an
institution that cannot qualify as his or her home, or is outside the U.S., monthly
payments may be made for the entire month. Similarly, if DME is returned to the
provider before the end of a payment month because the beneficiary died in that month or
because the equipment became unnecessary in that month, payment may be made for the
entire month.

110.2 - Repairs, Maintenance, Replacement, and Delivery
(Rev. 203, Issued: 02-13-15, Effective: 07-01-15, Implementation: 07-06-15)

Under the circumstances specified below, payment may be made for repair, maintenance,
and replacement of medically required DME, including equipment which had been in use
before the user enrolled in Part B of the program. However, do not pay for repair,