42 CFR 413.13 - Amount of payment if customary charges for services furnished are less than reasonable costs.
(a)Definitions. As used in this section -
Customary charges means the regular rates that providers charge both beneficiaries and other paying patients for the services furnished to them.
Fair compensation means the reasonable cost of covered services.
Nominal charge means a charge equal to 60 percent or less of the reasonable cost of a service.
Public provider means a provider operated by a Federal, State, county, city, or other local government agency or instrumentality.
(b)Application of the lesser of costs or charges (LCC) principle -
(1)General rule. Except as provided in paragraph (c) of this section, CMS pays providers the lesser of the reasonable cost or the customary charges for services furnished to Medicare beneficiaries. Reasonable cost and customary charges are compared separately for Part A services and Part B services.
(ii) The provider's customary charges for those services is $110,000.
(iii) CMS pays the provider $110,000 less the deductible and coinsurance amounts for which the beneficiaries are responsible.
(c)Exceptions to the LCC principle -
(iii) Any provider that requests payment of fair compensation and can demonstrate to its contractor that a significant portion of its patients are low income and that its charges are less than costs because its customary practice is to charge patients on the basis of their ability to pay.
(2)Services not subject to the LCC principle. The following services are not subject to the LCC principle:
(B) The rate of increase limits set forth in § 413.40.
(ii)Facility services related to ambulatory surgical procedures performed in outpatient hospital departments. Facility services related to ambulatory surgical procedures performed in hospital outpatient departments are subject to the payment methodology set forth in § 413.118.
(2) Amounts that represent the recovery of excess depreciation resulting from termination from the Medicare program or a decrease in Medicare utilization applicable to prior cost reporting periods, as provided in § 413.134.
(e)Reductions in customary charges. Customary charges are reduced in proportion to the ratio of the aggregate amount actually collected from charge-paying non-Medicare patients to the amount that would have been realized had customary charges been paid, if the provider -
(2) Failed to make a reasonable effort to collect those charges.
(f)Nominal charge determinations. In determining whether a provider's customary charges equal 60 percent or less of its reasonable costs, the following rules apply:
(1)General rule. The determination is based on charges actually billed to charge-paying, non-Medicare patients, and (except for clinical diagnostic laboratory tests that are paid under section 1833(h) of the Act) is made separately for Part A services and Part B services.
(2)Determination in special situations.
(i)Charges based on ability to pay. For providers that have a sliding scale or discounted charges based on patients' ability to pay, the determination -
(A) Is based on charges billed to all charge-paying patients;
(ii)HHA services. In determining nominal charges for HHAs, all Part A and Part B services, with the exception of DME, are considered together.
(iii)Graduate medical education. When making the nominal charge determination, graduate medical education payments (or the provider's reasonable costs for that education, if supported by appropriate data) are included in reasonable costs.
- 42 CFR 413.9 — Cost Related to Patient Care.
- 42 CFR 413.74 — Payment to a Foreign Hospital.
- 42 CFR 417.536 — Cost Payment Principles.
- 42 CFR 413.40 — Ceiling on the Rate of Increase in Hospital Inpatient Costs.
- 42 CFR 413.198 — Recordkeeping and Cost Reporting Requirements for Outpatient Maintenance Dialysis.
- 42 CFR 413.118 — Payment for Facility Services Related to Covered ASC Surgical Procedures Performed in Hospitals on an Outpatient Basis.
- 42 CFR 414.210 — General Payment Rules.
- 42 CFR 413.5 — Cost Reimbursement: General.
- 42 CFR 413.122 — Payment for Hospital Outpatient Radiology Services and Other Diagnostic Procedures.