94 STAT. 2612
PUBLIC LAW 96-499—DEC. 5, 1980
REIMBURSEMENT FOR INAPPROPRIATE INPATIENT HOSPITAL SERVICES
42 USC 1395X.
42 USC 1301.
42 USC 1396.
Occupancy rate.
42 USC 1396a.
SEC. 902. (a)(1) Section 1861(v)(l) of the Social Security Act is amended by adding at the end thereof the following new subparagraph: "(G)(i) In any case in which a hospital provides inpatient services to an individual that would constitute post-hospital extended care services if provided by a skilled nursing facility and a Professional Standards Review Organization (or, in the absence of such a qualified organization, an organization or agency with review responsibility as is otherwise provided for under part A of title XI) determines that inpatient hospital services for the individual are not medically necessary but post-hospital extended care services for the individual are medically necessary and such extended care services are not otherwise available to the individual (as determined in accordance with criteria established by the Secretary) at the time of such determination, payment for such services provided to the individual shall continue to be made under this title at the payment rate described in clause (ii) during the period in which— "(I) such post-hospital extended care services for the individual are medically necessary and not otherwise available to the individual (as so determined), "(II) inpatient hospital services for the individual are not medically necessary, and "(III) the individual is entitled to have payment made for posthospital extended care services under this title, except that if the Secretary determines that the hospital had (during the immediately preceding calendar year) an average daily occupancy rate of 80 percent or more, such payment shall be made (during such period) on the basis of the reasonable cost of inpatient hospital services. "(ii)(I) Except as provided in subclause (II), the payment rate referred to in clause (i) is a rate equal to the estimated adjusted Statewide average rate per patient-day paid for services provided in skilled nursing facilities under the State plan approved under title XIX for the State in which such hospital is located, or, if the State in which the hospital is located does not have a State plan approved under title XIX, the estimated adjusted State-wide average allowable costs per patient-day for extended care services under this title in that State. "(II) If a hospital has a unit which is a skilled nursing facility, the payment rate referred to in clause (i) for the hospital is a rate equal to the lesser of the rate described in subclause (I) or the allowable costs in effect under this title for extended care services provided to patients of such unit. "(iii) Any day on which an individual receives inpatient services for which payment is made under this subparagraph shall, for purposes of this Act (other than this subparagraph), be deemed to be a day on which the individual received inpatient hospital services. "(iv) For the purpose of determining the occupancy rate with respect to hospitals under clause (i)— "(I) public hospitals under common ownership may elect (with the approval of the Secretary) to be treated as a single hospital, and "(II) beginning two years after the date this subparagraph is first applied with respect to a hospital, the Secretary, to the extent feasible, shall not treat as an inpatient an individual with respect to whom payment is made to the hospital only because of this subparagraph or section 1902(h).".
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