(Medicare Benefit Policy Manual)

 A beneficiary that receives vaccinations required by a State or local jurisdiction.  This is compliant behavior to meet government requirements and not considered as voluntarily seeking medical care or services; or    A beneficiary who is involved in an accident and receives medical attention  at the accident scene, or in transport to the hospital, or at the hospital before being able to make their beliefs and wishes known; or    A beneficiary who is unconscious and receives emergency care and is hospitalized before regaining consciousness or bei ng able to locate his or her legal representative.   Nonexcepted medical treatment is defined as medical care or treatment other than excepted medical treatment. The term is intended to define the kinds of medical services that, if received by a beneficiary who has previously elected RNHCI services, would revoke the individual's election of services.  Examples of nonexcepted medical care could include but are not limited to the following:   A beneficiary receiving medical diagnosis and/or treatment for persistent headaches and/or chest pains.   A beneficiary in an RNHCI who is transferring to a community hospital to have radiological studies and the reduction of a fracture.   A beneficiary with intractable back pain receiving medical, surgical, or chiropractic services.    A beneficiary who has requested a physician to prescribe a wheelchair or other durable medical equipment item.   Note that the terms excepted and nonexcepted care represent mutually exclusive conditions under 1821 of the Social Security Act.  Medicare contractors may use the examples above in making determinations of excepted and nonexcepted care.  130.2.1 - Revocation of RNHCI Election  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Revocation is the cancell ation of the RNHCI election and can be achieved in two ways: either by submitting a written statement to the intermediary indicating the desire to cancel the election or by seeking nonexcepted medical care for which Medicare payment is sought.  See Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, Section 170 for instructions on submission of revocations to the specialty contractor.  See section 180 of that manual for a description of how Medicare non- specialty contractors revoke elections upon billing for nonexcepted services.  130.2.2 - RNHCI Election After Prior Revocation  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  After an initial revocation, the individual may again file a written election to receive the religious nonmedical health care benefit. This second election takes effect immediately upon its execution. If an individual revokes a second election, the next (third) election cannot become effective until 1 year after the date of the most recent revocation. Subsequent elections are not effective until 5 years after the most recent revocation. Once an election is revoked, Medicare payment cannot be made to an RNHCI unless a valid election is filed. The RNHCI revocation does not interfere with the beneficiarys ability to seek other Medicare services within the limits of his/her Medicare coverage.   130.3 - Medicare Payment for RNHCI Services and Beneficiary Liability  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Medicare pays for RNHCI services under TEFRA payment rules (see Pub. 15-2, Provider Reimbursement Manual, chapter 30).  RNHCI services are subject to the inpatient hospital cash deductible, when applicable.  If services are for the 61st through 90th day of a benefit period or are for lifetime reserve days, RNHCI services are subject to coinsurance (see Pub. 100- 01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Sections 10.1 and 10.2).  Under normal Medicare rules, a provider of services may onl y bill a beneficiary deductible and coinsurance amounts. However, total Medicare payments to RNHCIs are subject to limits established in sections 1821(c)(2) (A) or (B) of the Act. In the event that the Medicare program reduces payments to RNHCIs based on t hese limits, RNHCIs may also bill beneficiaries an amount equal to any such reduction.  130.4 - Coverage of RNHCI Items Furnished in the Home  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Prior to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, the Medicare programs RNHCI benefit was limited to inpatient services provided in an RNHCI facility.  The MMA revised sections 1821(a) and 1861 of the Social Security Act to extend coverage to RNHCI items and services that are provided in a beneficiarys home and that are comparable to items and services provided by a home health agency that is not an RNHCI.  Beneficiaries elect the RNHCI benefit if they are conscientiously opposed to accepting most medical treatment, since accepting such services would be inconsistent with their sincere religious beliefs.  The Medicare home health benefit provides skilled nursing, physical therapy, occupational therapy, speech language pathology and home health aide services to eligible beneficiaries under a physicians plan of care.  The home health benefit also provides medical supplies, a covered osteoporosis drug and durable medical equipment (DME) while under a plan of care (see chapter 7).   Medicare covers specified durable medical equipment and intermittent RNHCI nursing visits provided in the home to RNHCI beneficiaries.  These services comprise the RNHCI home benefit.  The remainder of the services covered under the Medicare home health benefit are medical in nature and must be provided under the order of a physician.  As such, these services conflict with RNHCI beneficiaries conscientious opposition to medical care.   The RNHCI home benefit must exclude the same services that are excluded from the home health benefit, which include: drugs and biologicals; transportation; services that would not be covered as inpatient services; housekeeping services; services covered under the End Stage Renal Disease program; prosthetic devices; and medical social services provided to family members.  These exclusions are defined at 42 CFR 409.49.  Additionally, the RNHCI home benefit excludes the items or services provided by any HHA that is not an RNHCI; or any supplier, independent RNHCI nurse or aide that is work ing directly for a beneficiary rather than under arrangements with the RNHCI.   Medicare requires a brief letter of intent from the provider in order to determine the number of RNHCIs that will be implementing the home service benefit.   In the case where an  RNHCI chooses to provide home services then only care on an intermittent basis, which is provided to an eligible beneficiary who is confined to their home for health reasons, will be covered under the home benefit.  The home benefit is not to be confused with hospice care, which may involve more frequent visits and can involve institutional services.  If for some reason the home serviced patient requires more than intermittent service, then institutional services may be required.  However, the patient would need to meet the criteria for admission to a RNHCI, or the patient would require another institutional setting not necessarily covered by Medicare.  Similar to the inpatient RNHCI benefit, the physician role in certifying and ordering the home benefit is replaced with the use of the RNHCI utilization review committee to review the need for care and plan for initial and continued care in the home setting.  The home benefit will also require a prompt review of admission to the home service, since the patien t must be fully eligible (have a health condition that keeps them confined to the home (42CFR409.42(a), have health needs that can be met with intermittent care, and have a valid election) before billable services can be rendered and Medicare payment reque sted.  Additionally the utilization review committee is responsible for review and approval of care plans and orders for DME items, and review of the need for the continuation of services.  As in the original RNHCI benefit, Medicare will only pay for nonme dical services in the home, but not for those religious items or services provided by the RNHCI.  Medicare covers these items and services for dates of service from January 1, 2005 through December 30, 2006.   Total Medicare payments under this benefit for each calendar year during this period are limited to $700,000.  130.4.1 - Coverage and Payment of Durable Medical Equipment Under the RNHCI Home Benefit  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Medicare covers a defined list of nonmedical DME items for RNHCI home services that are comparable to items used in the inpatient RNHCI setting and could be provided by an HHA.  The DME items include canes, crutches, walkers, commodes, a standard wheelchai r, hospital beds, bedpans, and urinals.  Those RNHCIs offering home services may order these items without a physician order and without compromising the beneficiary election for RNHCI care.  The need for each item of DME ordered must be supported by the RNHCI patients plan of care for the home setting and the RNHCI nurses notes for home services.  It must be noted that the benefit is applicable only to what we shall refer to as nonmedical DME items and does not include any of the related services provi ded by RNHCI staff members.   The RNHCI shall establish a payment arrangement with one or more DME suppliers to obtain any of the items on the DME list (below) they may require for a beneficiary.  The supplier will provide the items and related instructions  on use to the beneficiary/family/care giver.  The RNHCI will submit claims for these DME items to the RNHCI specialty FI.   The RNHCI must stress to suppliers that DME claims are not to be submitted to the DMERC because this will cause the beneficiarys election for RNHCI care to be revoked.   DME Items and HCPCS Codes for use by RNHCI Home Service Units Canes   E0100 Cane, includes canes of all materials, adjustable or fixed, with tip   E0105 Cane, quad or three prong, includes canes of all materials, adjus table or fixed with tip  Crutches   E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips   E0113 Crutch underarm, wood, adjustable or fixed, pair, with pad, tip and handgrip  E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips   E0116 Crutch underarm, other than wood, adjustable or fixed, with pad, tip and handgrip   Walkers   E0130 Walker, rigid (pickup), adjustable or fixed height   E0135 Walker, folding (pickup), adjustable or fixed height   E0141 Walker, rigid, wheeled, adjustable or fixed height   E0143 Walker, folding, wheeled, adjustable or fixed height   Commodes   E0163 Commode chair, stationary, with fixed arms   E0167 Pail or pan for use with commode chair   Wheelchairs   K0001 Standard wheelchair   Hospital Beds & Accessories   E0250 Hospital bed, fixed height, with any type side rails, with mattress   E0255 Hospital bed, variable height, hi- lo, with any type side rails, with mattress   E0260 Hospital bed, semi- electric (head and foot adjustment), with any type side rails, with mattress   E0275 Bed pan, standard, metal or plastic  E0276 Bed pan, fracture, metal or plastic  E0290 Hospital bed, fixed height, without side rails, with mattress   E0292 Hospital bed, variable height, hi- lo, without side rails, with mattress   E0325 Urinal; male, jug -type, any material   E0326 Urinal; female, jug -type, any material   Payment to RNHCIs for these specified DME items will be made based on the DME fee schedule.  Coinsurance applies to these items.  Deductible does not apply to these items.  130.4.2 - Coverage and Payment of Home Visits Under the RNHCI Home Benefit  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Medicare covers intermittent RNHCI nursing visits provided in the home to RNHCI beneficiaries.  The RNHCI nursing personnel may be skilled in ministering to a beneficiarys religious needs (not covered by Medicare), but do not have the training or nursing skill sets required of credentialed/licensed health care professionals (e.g., registered nurse).  While RNHCI nurses may provide tender loving care, they are focused primarily on religious healing and meeting basic beneficiary needs for assistance with activities of daily living (e.g., bathing, toileting, dressing , ambulation), as part of creating a milieu for religious healing.  The care provided by an RNHCI nurse is not at the level of either a registered nurse or a licensed practical nurse.  The physical care provided by an RNHCI nurse is at a level that could b e considered as supportive, but decidedly not skilled as defined by the Medicare program.