This regulation prohibits nursing facilities from charging residents' personal funds for items and services already covered under Medicare or Medicaid, except for applicable deductibles and coinsurance. Facilities may charge residents only for specifically requested non-covered items and services, provided the resident is informed orally and in writing of the charge before it is incurred. Certain categories of items (e.g., nursing care, meals, hygiene supplies, activities) are always included in the Medicare/Medicaid payment and may never be billed separately. Surveyors assess compliance by reviewing billing statements and interviewing residents or their representatives.
View official sourceF571 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.10(f)(11) The facility must not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare (except for applicable deductible and coinsurance amounts). The facility may charge the resident for requested services that are more expensive than or in excess of covered services in accordance with §489.32 of this chapter. (This does not affect the prohibition on facility charges for items and services for which Medicaid has paid. See §447.15 of this chapter, which limits participation in the Medicaid program to providers who accept, as payment in full, Medicaid payment plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.) (i) Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities must not charge a resident for the following categories of items and services: (A) Nursing services as required at §483.35. (B) Food and Nutrition services as required at §483.60. (C) An activities program as required at §483.24(c). (D) Room/bed maintenance services. (E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, bath soap, disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing assistance, and basic personal laundry. (F) Medically-related social services as required at §483.40(d). (G) Hospice services elected by the resident and paid for under the Medicare Hospice Benefit or paid for by Medicaid under a state plan. (ii) Items and services that may be charged to residents’ funds. Paragraphs (f)(11)(ii)(A) through (L) of this section are general categories and examples of items and services that the facility may charge to residents’ funds if they are requested by a resident, if they are not required to achieve the goals stated in the resident’s care plan, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid: (A) Telephone, including a cellular phone. (B) Television/radio, personal computer or other electronic device for personal use. (C) Personal comfort items, including smoking materials, notions and novelties, and confections. (D) Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare. (E) Personal clothing. (F) Personal reading matter. (F) Gifts purchased on behalf of a resident. (H) Flowers and plants. (I) Cost to participate in social events and entertainment outside the scope of the activities program, provided under §483.24(c). (J) Non-covered special care services such as privately hired nurses or aides. (K) Private room, except when therapeutically required (for example, isolation for infection control). (L) Except as provided in (e)(11)(ii)(L)(1) and (2) of this section, specially prepared or alternative food requested instead of the food and meals generally prepared by the facility, as required by §483.60. (1) The facility may not charge for special foods and meals, including medically prescribed dietary supplements, ordered by the resident’s physician, physician assistant, nurse practitioner, or clinical nurse specialist, as these are included per §483.60. (2) In accordance with §483.60(c) through (f), when preparing foods and meals, a facility must take into consideration residents’ needs and preferences and the overall cultural and religious make-up of the facility’s population. (iii) Requests for items and services. (A) The facility can only charge a resident for any non-covered item or service if such item or service is specifically requested by the resident. (B) The facility must not require a resident to request any item or service as a condition of admission or continued stay. (C) The facility must inform, orally and in writing, the resident requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be. GUIDANCE §483.10(f)(11) Residents must not be charged for universal items such as computers, telephones, television services or other electronic devices, books, magazines or newspaper subscriptions intended for use by all residents. PROCEDURES §483.10(f)(11) During interviews with residents or their representatives determine: • How and when they were notified by facility staff regarding the items and services that may not be covered during their stay at the facility. • Whether or not they may have been charged for items or services they believed were covered by the facility or their insurer. If concerns are raised review a resident’s billing statements to determine if they were charged for covered items or services. If charges found on these statements indicate that residents may have paid for covered items or services, determine if these items or services are over and above what is paid by Medicare or Medicaid. • How and when they were informed of any items or services that would be charged to them before these items or services are provided. KEY ELEMENTS OF NONCOMPLIANCE §483.10(f)(11) To cite deficient practice at F571, the surveyor’s investigation will generally show that the facility failed to do one or more of the following: • Made a charge against the resident’s personal funds for: o Any item or service covered under Medicare or Medicaid (except for applicable deductible or coinsurance amounts); or o Charged a resident for an item or services not required to achieve the goal stated in the resident’s care plan, without notifying the resident of the charge; or o Charged a resident for any item or service not covered under Medicare or Medicaid, but did not inform the resident orally and in writing of the charge; or o Charged a resident for specially prepared or alternative food when: • Ordered by a physician or non-physician practitioner, or • Prepared in consideration of the resident need, or • Prepared in consideration of the overall cultural and religious make-up of the resident population; or o Charged a resident for any noncovered item or service when not requested by the resident; or • Made the resident request any item or services as a condition of admission or continued stay.