relates to the nature of the services rendered to an individual (i.e., inpatient hospital or extended care); the end of a spell of illness is related to the type of the institution itself. Once a spell of illness has started, it continues as long as the individual remains an inpatient in a hospital which meets at least the requirements of section 1861 (e) (1), or extended care facility which meets at least the requirements of section 1861 (j) (1) of the Act, even though he may no longer require or receive skilled nursing care.* Thus, a spell of illness may continue even though the institution providing services to the individual is one that does not meet all of the requirements for participation or payment as a provider of services.

An inpatient of an extended care facility is a person who has been formally admitted to such facility for bed occupancy for the purpose of receiv ing inpatient services. There is no basis under section 1861 (a) of the Act, which defines a "spell of illness," for terminating an individual's status as an inpatient while physically in an extended care facility merely because the services which she is receiving are no longer covered.

It is recognized that there may be situations where these criteria for defining a "spell of illness" would appear harsh and disadvantageous to persons who remain in extended care facilities after having exhausted their benefit days, even though they may no longer be receiving skilled nursing care. However, the legislative history of hospital insurance indicates that Congress was aware of these limitations, and could have remedied them by substituting a subjective test for determining the end of a "spell of illness," (i.e., the type of care furnished), for the objective one now in the law, (i.e., the nature of the institution). Nevertheless, the requirements were set up in this manner specifically as a means of controlling the overall costs of the Medicare program, which was in turn intended to provide a basic protection against the costs of medical care for relatively short term acute illnesses. As recently as 1967, a change in the criterion for determining the end of a "spell of illness" was suggested to the congressional committees considering amendments to the Social Security Act. However, by permitting the objective test to remain in the law, it was the clear intent of Congress that an individual who has exhausted the maximum number of days of inpatient care in a hospital or extended care facility in a spell of illness should be able to qualify for such benefits again only if he does not receive institutional care for 60 consecutive days.

L's initial spell of illness, which began with her admission to the A Community Hospital on May 14, 1967, can be said to have continued beyond her discharge from the C Convalsecent Hospital, a participating extended care facility, on October 7, 1967, and until a period of 60 consecutive days had elapsed during which she was not an inpatient of a hospital or an extended care facility. Since this did not occur before December 4, 1967,

* Section 1861 (j) of the Act provides that "the term 'extended care facility' means an institution . . . which... (1) is primarily engaged in providing to inpatients A) skilled nursing care and related services for patients who require medical or irsing care, or (B) rehabilitation services for the rehabilitation of injured, disabled sick persons.

when L reentered the A Community Hospital, a new spell of illness did not start on that date and, therefore, the subsequent readmission to the C Convalescent Hospital occurred within the initial spell of illness for which I had already exhausted her entitlement to have payment made on her behalf for extended care services.

Accordingly, it is held, that L is not entitled to have payment of hospital insurance benefits made on her behalf for the services she received at the C Convalescent Hospital commencing on December 18, 1967.

SECTION 1861 (a) and (i).—HOSPITAL INSURANCE BENEFITS-DURATION OF SPELL OF ILLNESS-MORE THAN ONE TYPE OF ILLNESS INVOLVED CONTINUITY OF STAY AS INPATIENT IN EXTENDED CARE FACILITIES

20 CFR 405.120

SSR 70-17

An individual entitled to hospital insurance benefits was admitted in January 1967 to an extended care facility after a qualifying hospital stay for treatment of diverticulitis. She remained there continuously, using up the 100 days of post-hospital extended care services to which she was entitled in that spell of illness. On February 20, 1968, she was discharged to another extended care facility. While there, she fell and broke her hip, was readmitted to the hospital on May 17, 1968, for 3 weeks, and returned to the latter extended care facility. Held, a new spell of illness did not start on May 17, 1968, when she was readmitted to the hospital for treatment of a broken hip since there had not elapsed a period of 60 consecutive days during which she was not an inpatient either of a hospital or an extended care facility at any time since her initial hospital stay; thus, her second admission, and later readmission to the extended care facility on June 4, 1968, occurred within the initial spell of illness. Held further, since she had already exhausted the number of days of extended care in that spell of illness for which payment could be made on her behalf, no payment can be made to the extended care facility for the services it furnished the claimant beginning June 4, 1968.

An individual entitled to hospital insurance benefits under Part A of title XVIII of the Social Security Act is eligible to have payment made on his behalf to a participating extended care facility for up to 100 days of extended care services furnished to him in a spell of illness, if he was transferred to such facility within 14 days after discharge from a hospital in which he was an inpatient for not less than 3 consecutive days. As provided in section 1814(a) (2) (C) of the Act, the extended care services must be needed:

for any of the conditions with respect to which he was receiving inpatient hospital services. . . prior to transfer to the extended care facility or for a condition requiring such extended care services which arose after such transfer and while he was still in the facility for treatment of the condition or conditions for which he was receiving such inpatient hospital services; . . .

The term "spell of illness" is defined in section 1861 (a) of the Social Security Act as meaning a period of consecutive days—

(1) beginning with the first day (not included in a previous spell of illness) (A) on which such individual is furnished inpatient hospital services or extended care services, * • and

(2) ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of an extended care facility.

F, an individual entitled to hospital insurance benefits, was hospitalized for the treatment of diverticulitis and, after a qualifying hospital stay, was admitted to the A Nursing Home on February 1, 1967. She remained there as an inpatient until transferred to the D Convalescent Home on February 20, 1968. While there, she fell, broke her hip and was immediately hospitalized on May 17, 1968. On her discharge from the hospital, June 4, 1968, she was readmitted to the D Convalescent Home. Payment was made on F's behalf to the A Nursing Home for the posthospital nursing services she received there for the 100 days, February 1, 1967, through May 11, 1967. A claim has also been filed for payment to the D Convalescent Home on F's behalf for the extended care services she was furnished there beginning June 4, 1968, after her second hospital discharge on that date.

Since F's eligibility for extended care services was exhausted on May 11, 1967, she could become entitled to have payment made on her behalf for the services she was furnished by the D Convalescent Home beginning June 4, 1968, only if her second admission to the hospital on May 17, 1968, initiated a new "spell of illness" as defined above. In this connection, it is not material that the two periods of hospitalization were for different reasons, since the Social Security Act does not define a spell of illness in terms of type of illness.

A spell of illness begins when a beneficiary is furnished inpatient hospital services in a qualified hospital or extended care services in a qualified extended care facility. A "qualified" hospital is one which meets all the requirements to participate in the program as a provider of services and a "qualified" extended care facility is one which meets all the requirements to participate in the program, whether or not they actually participate. Once a spell of illness has started, it continues as long as the individual remains an inpatient in any hospital which meets at least the requirements of section 1861(e)(1) of the Act or in an extended care facility which meets at least the requirements of section 1861 (j) (1), even though he may no longer require or be receiving skilled nursing care.1

F was continuously an inpatient of a participating extended care facility after May 11, 1967, remaining in the A Nursing Home until her transfer to the D Convalescent Home on February 20, 1968. Therefore, the spell of illness which began when she was hospitalized initially for treatment of diverticulitis in February 1967 had not ended prior to her admission to a hospital for treatment of a broken hip, on May 17, 1968, since she had not been out of a hospital or an extended care facility for 60 consecutive days. A new spell of illness could not therefore have started on May 17, 1968, and

'For the rationale underlying these criteria, see SSR 69-62, C.B. 1969, p. 146.

her admission to the hospital on that date must be considered to have occurred within the initial spell of illness.

It is accordingly held that, since F had already exhausted her entitlement to have payment made on her behalf for extended care services during that spell of illness as of May 11, 1967, payment may not be made to the D Convalescent Home for services furnished F commencing June 4, 1968.

SECTION 1861 (i).-HOSPITAL INSURANCE BENEFITS

3-CONSECU

TIVE-DAY HOSPITAL STAY REQUIREMENT PRIOR TO TRANSFER TO EXTENDED CARE FACILITY

20 CFR 405.120 (c)

SSR 70-36

An individual entitled to hospital insurance benefits under Part A of title XVIII of the Social Security Act, is given emergency treatment in a hospital for a broken ankle and secondary shock, then transferred on the same day by ambulance to an extended care facility under orders from the attending physi cian at the hospital. A specialist enlisted by her familiy later diagnosed her condition as a stroke and she was returned to the hospital. Held, payment may not be made on her behalf for care and services furnished by the extended care facility because she was not an inpatient of a hospital for at least 3 consecutive days before her discharge from the hospital in connection with such transfer, as required by section 1861 (i) of the Social Security Act. The 3-day hospital stay requirement applies even though the decision to discharge the beneficiary on the same day she was admitted to the hospital may have been inappropriate from a medical viewpoint.

L, an individual entitled to hospital insurance benefits under Part A of title XVIII of the Social Security Act, was taken in an ambulance to a hospital, after she fell on the boardwalk at a beach resort. The attending physician on the hospital staff diagnosed L's case as a broken ankle and secondary shock, and placed her ankle in a cast. After ordering L placed under restraint, he had her transferred the same day to the N Nursing Home, an extended care facility, because L's husband, age 84, could not look after her at home, and her children lived too far away for her to travel in her condition. When L failed to recover the full use of her senses, her family became apprehensive and enlisted the services of a specialist, who diagnosed L as having suffered a stroke. After being confined in the extended care facility for almost 30 days she was taken back to the hospital, where she died 2 days later.

The claimant, L's son, filed a claim for reimbursement under title XVIII of the amount he paid the N Nursing Home for the services provided L by that facility. The claim was denied on the basis that L had not met the 3consecutive-day hospital stay requirement in section 1861 (i) prior to her admission to N Nursing Home.

Section 1861 (i) of the Social Security Act, as amended, 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."

While it is not here argued that L remained in the hospital 3 days before her transfer to the extended care facility as required by section 1861 (i) of the Act, it is contended that her discharge was not ordered pursuant to a "correct" medical determination that she be discharged, and therefore, since the medical determination was incorrect, the 3-day limitation is inoperable. The plain words of the statute in their ordinary meaning are clear and do not, under recognized rules of statutory construction, permit such a reading. This would, in effect, superimpose an additional and significant limitation on the 3-day condition of entitlement to post-hospital care in section 1861 (i) of the Act. There was no apparent intent on the part of Congress to limit the 3-day requirement to cases where the discharge of the patient is shown to be medically correct.

Since L was not a hospital inpatient for 3 days before her transfer to the N Nursing Home, as required by section 1861 (i) of the Social Security Act, it is accordingly held that payment may not be made on L's behalf for the extended care services provided by the N Nursing Home.

SECTION 1861 (i)-HOSPITAL INSURANCE BENEFITS 3-CONSECUTIVE-DAY HOSPITAL STAY REQUIREMENT PRIOR TO ADMISSION TO EXTENDED CARE FACILITY

20 CFR 405.120 (c)

SSR 69-63

A hospital insurance beneficiary under title XVIII of the Social Security Act was admitted as an inpatient to a participating hospital on June 6, 1968. She was discharged on June 8, 1968, and transferred to an extended care facility on that date. Held, payment for care and services furnished by the extended care facility may not be made on her behalf since she had not been an inpatient at the hospital for at least 3 consecutive days prior to admission to an extended care facility, as required under section 1861(i) of the Act. For purposes of this requirement, section 405.120(c) of Regulations No. 5 of the Social Security Administration (20 CFR 405.120 (c) specifically excludes the day of discharge in computing the number of days a person is an inpatient in a hospital.

L, who was entitled to hospital insurance benefits under Part A of title XVIII of the Social Security Act was admitted as an inpatient to the P Hospital on June 6, 1968, and discharged on June 8, 1968. On the same day, June 8, 1968, she was transferred to the O Convalescent Hospital, a participating extended care facility. Program payment to the O Convalescent Hospital on L's behalf for the services she received there was denied because L had not met the 3-consecutive-day hospital stay requirement in section 1861 (i) prior to her admission to the extended care facility. L protested this decision on the basis that she felt she had been an inpatient on 3 consecutive days, i.e., June 6, 1968; June 7, 1968; and June 8, 1968.

Section 1861 (i) of the Social Security Act, as amended, provides in pertient part that the term "post-hospital extended care services" means exnded care services furnished an individual who has met the requirements