SSR 68-39: Sections 216(j) and 1861(l).—Post-Hospital Extended Care Services—Patent Admitted to Extended Care Facility More Than 14 Days After Discharge From Hospital
20 CFR 405.12
Where the 14th day after an individual's discharge from a qualifying hospital fell on a Saturday, and the individual (who was entitled to hospital insurance benefits under Part A of title XVIII of the Act) was not admitted to an extended care facility until the following Monday because the facility did not admit patients on weekends, and where, under the definition of "extended care services" in section 1861(i) of the act, such services are not covered under Part A of title XVIII unless (among other requirements) the individual is admitted to an extended care facility within 14 days after discharge from a hospital, held, the provisions of section 216(j) of the Act are not applicable for the purpose of extending the 14-day time requirement in section 1861(j), since such time requirement is not a time limitation within which a claimant must act to protect or perfect a right, but is an objective standard for determining continuity of medical condition between hospital and extended care services.
Payment may be made under Part A of title XVIII of the Act to a participating extended care facility for post-hospital extended care services furnished an individual by the facility, or by others under arrangements with the facility, for up to 100 days during any spell of illness, if such individual is entitled to hospital insurance benefits under Part A and certain other conditions are met.
Section 1861(i) of the Act defines "post-hospital extended care services" for purposes of title XVIII, and provides in pertinent part that:
The term "post-hospital extended care services" means extended care services furnished an individual after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer. For purposes of the preceding sentence, items and services shall be deemed to have been furnished to an individual after transfer from a hospital, and he shall be deemed to have been an inpatient in the hospital immediately before transfer therefrom, if he is admitted to the extended care facility within 14 days after discharge from such hospital * * *.
H, who was entitled to hospital insurance benefits under Part A of title XVIII of the Act, was discharged from a qualifying hospital stay of at least 3 days on February 25, 1967. The 14th day following discharge from the hospital fell on Saturday, March 11, 1967. H was admitted to a participating extended care facility on Monday, March 13, 1967. However, payment to the extended care facility on H's behalf was denied on the ground that services furnished H by the facility were not "post-hospital extended care services" as defined by section 1861(i) of the Act, and hence were not covered by Part A of title XVIII, since H was not admitted to the facility within 14 days after discharge from the hospital. H protested this denial, alleging that it was the practice of the extended care facility not to admit patients on weekends.
Section 216(j) of the Act provides, in part, as follows:
(j) Where this title, any provision of another law of the United States * * * relating to or changing the effect of this title, or any regulation * * * provides for a period within which an act is required to be done which affects eligibility for or the amount of any benefit or payment under this title or is necessary to establish or protect any rights under this title, and such period ends on a Saturday, Sunday, or legal holiday, or any other day all or part of which is declared to be a nonwork day for Federal employees by statute or Executive order, then such act shall be considered as done within such period if it is done on the first day thereafter which is not a Saturday, Sunday, or legal holiday or any other day all or part of which is declared to be a nonwork day for Federal employees by statute or Executive order. * * *.
Section 1872 of the Act provides in part that:
The provisions of section * * * 216(j) * * * shall also apply with respect to this title [title XVIII of the Act] to the same extent as they are applicable with respect to title II. (Emphasis supplied.)
Thus, the question presented in this case is whether the provisions of section 216(j) of the Act may be interpreted as applying to the 14-day requirement of section 1861(i) of the Act, so that the extended care services furnished H may be held to be covered services reimbursable under Part A of title XVIII.
The purpose of section 216(j), added to the Act by the Social Security Amendments of 1960 (74 Stat. 924), was to give recognition to the fact that governmental offices are not officially open for the transaction of business on weekends and certain holidays. Individuals thus are unable at times to complete actions which are required to perfect rights under governmental programs within the designated time periods established for such actions where the last day of the period falls on a governmental nonwork day. The report of the Senate Committee on Finance explains the purpose and the scope of section 216(j) as follows (Senate Report 1856, 86th Cong., 2d Sess. (1960), p. 35):
The law provides that certain actions, such as applying for a lump-sum death payment, filing proof of support, or requesting a review in the U.S. district court of a decision of the Secretary, must be taken within a specified period of time in order to be valid. People sometimes try to meet a deadline of this sort by taking the appropriate action on the last day of the period in which it can be done, and if the deadline date falls on a nonwork day, the claimant then finds that he cannot meet the deadline because the offices are closed. The bill would eliminate this problem by extending any deadline date that falls on a day that is not officially a full workday to the first official full workday immediately following the deadline date.
The language of the statute, supplemented by its Congressional history, thus gives strong support for the view that section 216(j) is applicable to actions which are required to establish entitlement to benefits or to protect appeal rights from adverse decisions by filing applications, notices, or other documents which must be submitted to governmental offices within specified times. The time factor for determining whether or not services rendered a beneficiary in an extended care facility are "extended care services" does not pertain to the types of conditions to which section 216(j) applies.
Section 1861(i) of the Act, supra, defines what shall constitute "extended care services" for purposes of title XVIII. The services so defined, under the terms of the statute, are inpatient health care services in an institution which meets the definition of an "extended care facility." They are services required to be given on an inpatient basis for a medical situation which initially required a period of inpatient hospital service and must be a consequence to such hospital service. The definition therefore incorporates these definitional conditions in terms of a time sequence as the measure of correlation between the inpatient hospital stay and the subsequent admission to the extended care facility. The 14-day measure prescribed by the statute does not establish a time limitation within which a beneficiary must take action to perfect a right, but an objective, albeit arbitrary, standard for determining continuity between hospital and extended care service.
This understanding of the 14-day time factor is clearly borne out in the legislative history, which states, in this regard:
The post-hospital extended care benefits which would be provided under the hospital insurance plan would cover care in qualified extended care facilities in cases where the patient was hospitalized for 3 or more consecutive days and then transferred to the facility for continued care of the same illness within 14 days of his hospital discharge. * * *
The hospital-transfer requirement is intended to help limit the payment of the extended care benefits to persons for whom such care may reasonably be presumed to be required in connection with continued treatment following inpatient hospital care and makes less likely unduly long hospital stays. This requirement also helps to assure that before a patient is admitted to an extended care facility his medical condition and needs will have been adequately medically appraised. Immediate transfer from a hospital to a posthospital extended care facility is not required because, in some instances, case in such a facility might be found to be needed, for example, only after a trial at convalescent care at the patient's home proves unsuccessful. * * *. House Report No. 213, 89th Cong. 1st Sess. (1965), at page 27. (See also Senate Report 404, Part 1, 89th Cong., 1st Sess., at page 30.)
Congressional concern with correlation between the prior hospital stay and subsequent admission to an extended care facility is further demonstrate as follows:
* * * Items and services will be deemed to have been furnished to an individual after transfer from a hospital, and he will be deemed to have been an inpatient of the hospital immediately before transfer, if he is admitted to the extended care facility within 14 days after discharge from such hospital. (House report, ibid, p. 164.)
Based on the foregoing, it is held that the provisions of section 216(j) of the Act are not applicable to the 14-day time requirement of section 1861(i) of the Act. Accordingly, it is further held that the extended care services furnished H were not "post-hospital extended care services" as defined by section 1861(i), and therefor payment may not be made under Part A of title XVIII on H's behalf for such services.