(Medicare General Information, Eligibility, and Entitlement)

Medicare General Information, Eligibility, and Entitlement  Chapter 1 - General Overview   Table of Contents  (Rev. 12425; Issued: 12-21-23)   Transmittals for Chapter 1   10 - General Program Benefits  10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health, and Skilled Nursing Facility (SNF) Services - A Brief Description  10.2 - Home Health Services  10.3 - Supplementary Medical Insurance (Part B) - A Brief Description  10.4 - Basis for Payment  20 - Administration of the Medicare Program - Introduction 20.1 - Financing the Program  20.2 - Discrimination Prohibited  20.3 - Fraud and Abuse - General 20.3.1 - Definition and Examples of Fraud  20.3.2 - Definition and Examples of Abuse  30 - Federal Government Administration of the Health Insurance Program  30.1 - CMS Responsibilities  30.2 - Public Health Service Responsibilities  30.3 - State Agencies  30.3.1 - Certification by State Agencies  30.3.2 - Consultation by State Agencies  30.3.3 - Coordination by State Agencies   40 - Role of A/B MACs (A) and (HHH)  40.1 - Assignment of A/B MAC (A) and (HHH)  40.2 - A/B MAC (A) and (HHH)  Service to Home Health Agencies (HHAs)  50 - Role of A/B MACs (B)  60 - Background and Responsibilities of the Peer Review Organization (PROs)  60.1 - Purpose of PRO Review for the Individual Medicare Beneficiaries  60.2 - PRO Responsibility for the Overall Approach to Health Care  60.3 - Other PRO Responsibilities  60.4 - Statutory Obligations of Practitioners and Other Persons  60.5 -  Responsibilities of Designated Agents Working With PROs; Organizations Subcontracted for Review  70 - Institutional Planning and Budgeting 80 - CMS Managed Modules for Software Programs and Pricing/Coding Files    10 - General Program Benefits  (Rev. 1, 09- 11-02)  The Health Insurance for the Aged and Disabled Act (title XVIII of the Social Security Act), known as "Medicare," has made available to nearly every American 65 years of age and older a broad program of health insurance designed to assist the nation's elderly to meet hospital, medical, and other health costs.  Health insurance coverage has also been extended to persons under age 65 qualifying as disabled and those having end stage renal disease (ESRD) or Lou Gehrig's disease.  The program includes two related health insurance programs --hospital insurance (HI) (Part A) and supplementary medical insurance (SMI) (Part B).  10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description  (Rev. 94, Issued: 10- 16-15, Effective: 11 -16-15, Implementation: 11- 16-15)  Hospital insurance is designed to help patients defray the expenses incurred by hospitalization and related care.   In addition to inpatient hospital benefits, hospital insurance covers posthospital extended care in SNFs and posthospital care furnished by a home health agency in the patient's home.  Blood clotting factors, for hemophilia patients competent to use such factors to control bleeding without medical or other supervision, and items related to the administration of such factors, are also a Part A benefit for beneficiaries in a covered Part A stay.  The purpose of these additional benefits is to provide continued treatment after hospitalization and to encourage the appropriate use of more economical alternatives to inpatient hospital care.  Program payments for services rendered to beneficiaries by providers (i.e., hospitals, SNFs, and home health agencies) are generally made to the provider.  In each benefit period, payment may be made for up to 90 inpatient hospital days, and 100 days of posthospital extended care services.   Hospices also provide Part A hospital insurance services such as short -term inpatient care.  In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill.  An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.   The Part A benefit categories of inpatient hospital services and SNF services are each subject to separate and mutually exclusive day limits, so that the use of benefit days under one of these benefits does not affect the number of benefit days that remain available under the other.  Accordingly, the 90 days of inpatient hospital benefits (plus 60 nonrenewable lifetime reserve days -- see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 5) that are available to a beneficiary in a hospital do not count against the 100 days of posthospital extended care benefits that are available in a SNF, and vice- versa.   10.2 - Home Health Services  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  To qualify for home health benefits under either Part A or Part B of the program, a beneficiary must be confined to his/her home, under the care of a physician, and in need of skilled nursing services on an intermittent basis, physical therapy, or speech -language pathology services.  Being "confined to the home" does not mean a beneficiary can never leave the home.  See chapter 7 of the Benefit Policy publication for the definition of homebound.  A beneficiary who requires one or more of these services in the treatment of his/her illness or injury and otherwise qualifies for home health benefits is eligible to have payment made on his/her behalf for the skilled nursing, physical therapy or speech -language pathology services he needs, as well as for any of the other home health services specified in the law.  These services include occupational therapy, medical social services, the use of medical supplies and medical appliances, and the part-time or intermittent services of home health aides.  Conversely, a patient who does not require intermittent skilled nursing or physical therapy or speech- language pathology services cannot qualify to have payment made under the program for any home health services furnished him.  Excluded as home health services are the costs of housekeepers, food service arrangements, and transportation to outpatient facilities.   To be covered, the home health services must be needed for a condition for which the patient required inpatient hospital services or extended care services.  See the chapter 7 of the Benefit Policy publication for a description of services covered.  Discharge from the hospital must have occurred in a month in which the patient has attained age 65 or was entitled to health insurance benefits under the disability or chronic renal disease provisions of the law.   Home health services are services provided by a home health agency or by others under arrangements with such an agency.  A home health agency is a public agency or private organization which is primarily engaged in providing skilled nursing and other therapeutic services.  Where applicable the agency must be licensed under State or local law, or be approved by the State or local licensing agency as meeting the licensing standards.  Examples of home health agencies are visiting nurse associations, official health agencies, and hospital -based home care programs.  To participate in the health insurance program, a home health agency must meet certain other requirements included in the law as well as health and safety conditions prescribed by the Secretary of the Department of Health and Human Services.  It may not qualify under hospital insurance, however, if it is primarily engaged in the treatment of mental diseases; such an agency may qualify only under supplementary medical insurance.   Home health services are usually furnished on a visiting basis in a place of residence used as the individual's home.  However, outpatient services in a hospital, SNF, or rehabilitation center are covered home health services, if arranged for by a home health agency, when equipment is required that cannot be made available in the patient's home.  The services of an intern or resident -in-training are covered if the agency has an affiliation with or is under common control of a hospital providing such medical services and the agency bills for such services.   Prior to July 1, 1981, home health services under hospital insurance included up to 100 home health visits, after the beginning of one benefit period and before the beginning of the next.  The visits must have been furnished to a patient within 1 year of his/her most recent discharge from a hospital where he was an inpatient for at least 3 consecutive calendar days (counting the day of admission, but not the day of discharge).  If, after his/her hospitalization, he had a covered stay in a SNF, the 1 year during which the patient may receive home health services began with the discharge from the SNF.  A plan of treatment must have been established within 14 days after the hospital or SNF discharge.  Home health services were also provided under supplementary medical insurance where the 100- visit limit under Part A was exceeded.   Effective July 1, 1981, the 100- visit limitation under Parts A and B, and the prior inpatient stay requirement under Part A were eliminated.  In addition, a person could qualify for home health services based on his or her need for skilled nursing services on an intermittent basis, physical therapy, speech- language pathology services, or occupational therapy.  Effective December 1, 1981, occupational therapy was eliminated as a basis for entitlement to home health services. However, if a person has otherwise qualified for home health services because of the need for skilled nursing care, physical therapy or speech- language pathology services, the patient's eligibility for home health services may be extended solely on the basis of the continuing need for occupational therapy.   Effective January 1, 1998, the first 100 visits must be paid under Part A if the beneficiary is entitled under Part A, and the remainder of the visits may be paid under Part B.  10.3 - Supplementary Medical Insurance (Part B) - A Brief Description  (Rev. 12425, Issued: 12- 21-23, Effective: 01- 01-24, Implementation: 01- 02-24)    To obtain SMI, an eligible individual must enroll during an enrollment period and pay the required premiums.  An individual is eligible to enroll if they are entitled to HI or are 65 years of age and a citizen or resident alien who meets certain residence requirements.  SMI provides for payment to participating providers for furnishing covered services after a yearly cash deductible is met.  The voluntary medical insurance plan is designed to supplement the basic hospital insurance coverage.  It provides coverage for home health visits not available under hospital insurance (e.g., no Part A entitlement or visits after the first 100 visits) and for medical and other health services.  Payment may not be made under Part B for any service that may be paid under Part A.  However, where payment is not possible under Part A (e.g., no Part A entitlement or benefits are exhausted) payment may be made under Part B if the service is covered.    Subject to coverage and limitations described in the Benefit Policy Publication, the following services are covered under Part B.     Physicians' services;     Services and supplies (including drugs and biologicals which are not usually self -administered by the patient) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;     Hospital services (including drugs and biologicals which are not usually self -administered by the patient) incident to physicians' services rendered to outpatients and partial hospitalization or intensive outpatient  services incident to such services;     Diagnostic services which are:  (i) furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, and (ii) ordinarily furnished by such hospital (or by others under such arrangements) to its outpatients for the purpose of diagnostic study;     Outpatient physical therapy services, occupational therapy services, and speech- language pathology services;     Rural health clinic services and Federally qualified health center services;     Home dialysis supplies and equipment, self -care home dialysis support services, and institutional dialysis services and supplies;     Antigens (subject to quantity limitations prescribed in regulations by the Secretary) prepared by a physician, as defined in section 1861(r)(1) of the Act, for a particular patient, including antigens so prepared which are forwarded to another qualified person (including a rural health clinic) for administration to such patient, from time to time, by or under the supervision of another such physician;     Services furnished pursuant to a contract under section 1876 of the Act to a member of an eligible organization by a physician assistant or by a nurse practitioner and such services and supplies furnished as an incident to his/her service to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician's service; and, services furnished pursuant to a risk- sharing contract under section 1876(g) of the Act to a member of an eligible organization by a clinical psychologist (as defined by the Secretary) or by a clinical social worker, and such services and supplies furnished as an incident to such clinical psychologist's services or clinical social worker's services to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician's service;