(Medicare General Information, Eligibility, and Entitlement)

The issuance by a State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine.  If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards determine whether a particular physician has legal authorization.  If State licensing law limits the scope of practice of a particular type of medical practitioner , only the services within the limitations are covered.   NOTE:   The term physician does not include such practitioners as a Christian Science practitioner or naturopath.  70.1 - Doctors of Medicine and Osteopathy  (Rev. 1, 09-11-02)  The requirement that a doctor of medicine be legally authorized to practice medicine and surgery by the State in which he/she performs his/her services means a physician is licensed to practice medicine and surgery.   A doctor of osteopathy who is legally authorized to practice medicine and surgery by the State in which he/she performs his/her services qualifies as a physician.  In addition, a licensed osteopath or osteopathic practitioner qualifies as a physician to the extent that he/she performs services within the scope of his/her practice as defined by State law.   70.2  Dentists  (Rev. 1, 09-11-02)  A dentist qualifies as a physician if he/she is a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he/she performs such function and who is acting within the scope of his/her license when he/she performs such functions.  Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy and dentistry; e.g., dental examinations to detect infections prior to certain surgical procedures, treatment of oral infections and interpretations of diagnostic X -ray examinations in connection with covered services.  Because the general exclusion of payment for dental services has not been withdrawn, payment for the services of dentists is also l imited to those procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting the teeth.  The coverage of any given dental service is not affected by the professional designation of the physician rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine or osteopathy.  70.3 - Doctors of Podiatric Medicine  (Rev. 1, 09- 11-02)  A doctor of podiatric medicine is a physician, but only with respect to those functions which he/she is legally authorized to perform in the State in which he/she performs them.  The professional services furnished by a doctor of podiatric medicine within the scope of his/her applicable State license (except services which are specifically excluded) are physician's services payable on a reasonable charge basis under Part B.  Where permissible by State law, these services include ordering laboratory tests that are reasonably related to the legal scope of podiatric practice, that are reasonable and necessary for the diagnosis or treatment of a patient's condition and are not in connection with excluded services, such as treatment of flat foot and routine foot care.   A doctor of podiatric medicine may hold any of the following professional degrees:  Pod. D. or D. P. (Doctor of Podiatry), D.S.C. (Doctor of Surgical Chiropody), D.P.M. (Doctor of Podiatric Medicine), D.S.P. (Doctor of Surgical Podiatry), Graduate in Podia try, Master Chiropodist, Graduate Chiropodist, or in some instances another podiatry degree.  Within a particular State, all individuals holding any of these degrees are licensed to perform the same functions; however, there are variations from State to St ate as to the authorized scope of podiatric practice.   For purposes of the Medicare program, a doctor of podiatric medicine is considered a physician for any of the following purposes:    Making the required physician certification and recertification of the medical necessity for services;    Having a patient in a home health agency under his/her care, and establishing and periodically reviewing a home health plan of treatment; or    Serving as a member of a Utilization Review (UR) committee, but only if at least two of the physicians on the UR committee are doctors of medicine or osteopathy.  The performance of these functions must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable State law.   A doctor of podiatric medicine is not a physician for the purpose of performing any of the physician activities required to qualify an institution or organization as a SNF.   70.4 - Physicians in Federal Hospitals  (Rev. 1, 09- 11-02)  There are many physicians performing services in hospitals operated by the Federal Government, e.g., military, Veterans Administration, and Public Health Service hospitals.  Normally, the services provided by a physician in a Federal hospital are not payable except when the hospital provides services to the public as a community institution.  A physician working in the scope of his/her Federal employment is considered a physician even though he/she may not have a license to practice in the State in which he /she is employed.  70.5  Optometrists  (Rev. 1, 09- 11-02)  A.  Services Furnished Through March 31, 1987  Prior to April 1, 1987, a doctor of optometry who was legally authorized to practice optometry by the State in which he or she performed such a function was considered a physician under Medicare, but only for the purpose of services related to the condition of aphakia.  Aphakia is defined as the absence of the natural crystalline lens of the eye, whether or not an intraocular lens has been implanted.  The services performed by optometrists within this definition were subject to limitations set by the State relating to the scope of practice of optometry.  The following are examples of examination services which were covered when furnished by optometrists if related to the condition of aphakia: case history, external examination, ophthalmoscopy, biomicroscopy, tonometry, visual fields, ocular motility, binoc ular function, and evaluation for contact lenses, if the optometrist furnishing these services is legally authorized to perform them.  B.  Services Furnished After March 31, 1987   Effective April 1, 1987, a doctor of optometry is considered a physician with respect to all services the optometrist is authorized to perform under State law or regulation.  To be covered under Medicare, the services must be medically reasonable and necessary for the diagnosis or treatment of illness or injury, and must meet all applicable coverage requirements.  (See Benefit Policy Manual for information concerning exclusions from coverage that apply to vision care services.)   70.6  Chiropractors (Rev. 1, 09- 11-02)  A.  General   A licensed chiropractor who meets uniform minimum standards (see subsection C) is a physician for specified services.  Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by X -ray, provided such treatment is legal in the State where performed.  All other services furnished or ordered by chiropractors are not covered.  An X -ray obtained by a chiropractor for his or her own diagnostic purposes before commencing treatment may suffice for claims documentation purposes.  This means that if a chiropractor orders, takes, or interprets an X -ray to demonstrate a subluxation of the spine, the X -ray can be used for claims processing purposes.  However, there is no coverage or payment for these services o r for any other diagnostic or therapeutic service ordered or furnished by the chiropractor.   In addition, in performing manual manipulation of the spine, some chiropractors use manual devices that are hand -held with the thrust of the force of the device being controlled manually.  While such manual manipulation may be covered, there is no separate payment permitted for use of this device.   B.  Licensure and Authorization to Practice   A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished.  C.  Uniform Minimum Standards   l. Prior to July 1, 1974, Chiropractors licensed or authorized to practice prior to July 1, 1974, and those individuals who commenced their studies in a chiropractic college before that date must meet all of the following minimum standards to render payable services under the program:    a. Preliminary education equal to the requirements for graduation from an accredited high school or other secondary school;    b. Graduation from a college of chiropractic approved by the State's chiropractic examiners that included the completion of a course of study covering a period of not less than 3 school years of 6 months each year in actual continuous attendance covering adequate course of study in the subjects of anatomy, physiology, symptomatology and diagnosis, hygiene and sanitation, chemistry, histology, pathology, and principles and practice of chiropractic, including clinical instruction in vertebral palpation, nerve tracing and adjusting; and   c. Passage of an examination prescribed by the State's chiropractic examiners covering the subjects listed in subsection b.  2. After June 30, 1974 - Individuals commencing their studies in a chiropractic college after June 30, 1974, must meet all of the following additional requirements:    a. Satisfactory completion of 2 years of pre -chiropractic study at the college level;    b. Satisfactory completion of a 4- year course of 8 months each year (instead of a 3-year course of 6 months each year) at a college or school of chiropractic that includes not less than 4,000 hours in the scientific and chiropractic courses specified in subsection 1.b, plus courses in the use and effect of X -ray and chiropractic analysis; and   c. The practitioner must be over 21 years of age.   70.7 - Interns and Residents  (Rev. 1, 09- 11-02)  A.  General   For Medicare purposes, the terms "interns" and "residents" include physicians participating in approved graduate training programs and physicians who are not in approved programs but who are authorized to practice only in a hospital setting; e.g., individuals with temporary or restricted licenses, or unlicensed graduates of foreign medical schools.  Where a senior resident has a staff or faculty appointment or is designated, for example, a "fellow," it does not change the resident's status for the purposes of Medicare coverage and payment.  As a general rule, services of interns and residents are paid as provider services by the A/B MAC (A).   B.  Services Furnished by Interns and Residents Within the Scope of an Approved Training Program   Medical and surgical services furnished by interns and residents within the scope of their training program are covered as provider services.  Effective with services furnished on or after July 1, 1987, this includes services furnished in a setting which i s not part of the provider where a hospital has agreed to incur all or substantially all of the costs of training in the nonprovider facility.  The Medicare A/B MAC (A) is required to notify the A/B MAC (B) of such agreements.  Where the provider does not incur all or substantially all of the training costs and the services are performed by a licensed physician, the services are payable on a fee schedule basis by the A/B MAC (B).  Prior to July 1, 1987, the covered services of interns and residents were pai d by the A/B MAC (B) on a reasonable charge basis as physician services if furnished by a licensed physician off the provider premises regardless of who incurred the training costs.  C.  Services Furnished by Interns and Residents Outside the Scope of an Approved Training Program -Moonlighting   Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed outside the facility where they have their training program, are covered as physicians' services and paid on a fee schedule or reasonable charge basis where the requirements in the first 2 bullets below are met.  Medical and surgical services furnished by interns and residents that are not related to their training program, and are performed in an outpatient department or emergency room of the hospital where they have their training program, are covered as physicians' services and paid on a fee schedule or reasonable charge basis where the following criteria are met:   The services are identifiable physicians' services, the nature of which requires performance by a physician in person and which contributes to the diagnosis or treatment of the patient's condition;   The intern or resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the State in which the services are performed; and    The services performed can be separately identified from those services that are required as part of the training program.  When these criteria are met, the services are considered to have been furnished by the individuals in their capacity as physicians and not in their capacity as interns and residents.   80 - Health Maintenance Organizations (HMOs) Defined  (Rev. 1, 09- 11-02)  An HMO for Medicare purposes is a public or private organization that provides, either directly or through arrangement with others, comprehensive health services to enrolled members.  An HMO must service those who live within a specified service area.  It must provide services based on a predetermined periodic rate or periodic per capita rate basis without regard to the frequency or extent of covered services it furnishes.  An HMO must also meet other statutory requirements.