(Medicare Benefit Policy Manual)

Eye care services furnished by anyone other than the investigator (or a practitioner who assists the investigator, as described in the preceding paragraph) are not covered during the period the IOL is being investigated, unless the services are not related  to the investigation.  B.  Concurrent Care   Where more than one practitioner furnishes concurrent care, services furnished to a beneficiary by both an ophthalmologist and another physician (including an optometrist) may be recognized for payment if it is determined that each practitioners services were reasonable and necessary.  (See 30.E.)  30.5 - Chiropractors Services  (Rev. 23, Issued: 10-08- 04, Effective: 10 -01-04, Implementation: 10-04-04) B3-2020.26  A chiropractor must be licensed or legally authorized to furnish chiropractic services by the State or jurisdiction in which the services are furnished.  In addition, a licensed chiropractor must meet the following uniform minimum standards to be considered a physician for Medic are coverage.  Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed.  All other services furnished or ordered by chiropractors are not covered.  If a chiropractor orders, takes, or interprets an x-ray or other diagnostic procedure to demonstrate a subluxation of the spine, the x-ray can be used for documentation.  However, there is no coverage or payment for these services or for any other diagnostic or therapeutic service ordered or furnished by the chiropractor. For detailed information on using x-rays to determine subluxation, see 240.1.2.  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.  A.  Uniform Minimum Standards   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 three minimum standards to render payable services under the program:   Preliminary education equal to the requirements for graduation from an accredited high school or other secondary school;   Graduation from a college of chiropractic approved by the States 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   Passage of an examination prescribed by the States chiropractic examiners covering the subjects listed above.  After June 30, 1974  Individuals commencing their studies in a chiropractic college after June 30, 1974, must meet all of the above three standards and all of the following additional requirements:   Satisfactory completion of 2 years of pre- chiropractic study at the college level;    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 the s econd bullet under  Prior to July 1, 1974 above, plus courses in the use and effect of x- ray and chiropractic analysis; and    The practitioner must be over 21 years of age.  B.  Maintenance Therapy   Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable.  Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.  When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment be comes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. For information on how to indicate on a claim a treatment is or is not maintenance, see 240.1.3.  30.6 - Indian Health Service (IHS) Physician and Nonphysician Services  (Rev. 86, Issued: 04-18- 08, Effective: 09 -11-06, Implementation: 05-19-08)  This information can also be found in the Medicare Claims Processing Manual, Publication 100-04, chapter 19.  Section 1880 of Title XVIII of the Social Security Act (the Act) provides an exception for Indian Health Service to the general prohibition of payment to Federal Agencies.  The following facilities, which were unable to bill for practitioner services prior to BIPA, may now be paid:   Outpatient departments of IHS operated hospitals that meet the definition of provider-based in 42 CFR 413.65; and    Outpatient clinics (freestanding) operated by the IHS.  The following facilities, which were limited by 1880  of the Act, may be paid for services under BIPA or may be paid under another authority under which it qualifies.   Outpatient departments of tribally operated hospitals that are operated by a tribe or tribal organization; and   Other outpatient facilities that are tribally operated regardless of ownership.   See the Medicare Claims Processing Manual chapter 19 for a description of billing procedures, physician and non-physician services and other Part B services.  30.6.1 - Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and Clinics  (Rev. 86, Issued: 04-18- 08, Effective: 09 -11-06, Implementation: 05-19-08)  Section 1880 of the Act, as amended by 630 of the Medicare Modernization Act of 2003 (MMA), expands the scope of items and services for which payment may be made to IHS facilities, providers and suppliers to include all Part B covered items and services f or which payment may be made under Part B, subject to certain limitations as specified in 1880(e)(1)(A) of the Act, for a 5-year period beginning January 1, 2005.  Specifically, for the 5 -year period beginning January 1, 2005, IHS facilities, providers and suppliers may bill Medicare for the following Part B services:    Durable medical equipment  Prosthetics and orthotics  Prosthetics devices   Therapeutic shoes   Surgical dressings and splint casts  Drugs (A/B MAC (B) and DME MAC)   Clinical laboratory services, and  Ambulance services   Screening and preventive services not already covered   See Pub. 100.04, chapter 19, Medicare Claims Processing Manual, for more information on these benefits and the effective date for each of these benefits.   40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage  (Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)  Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B.  Also, they are not allowed to charge beneficiaries in excess of the limits on charges that apply to the item or service being furnished.  However, a physician or practitioner (as defined in 40.4) may opt out of Medicare.  A physician or practitioner who opts out is not required to submit claims on behalf of beneficiaries and also is excluded from limits on charges for Medicare covered services.   Only physicians and practitioners that are listed in 40.4 may opt out.   The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiarys legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.  However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.   In some circumstances, a non -opt-out physician/practitioner, or other supplier, is required to provide an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary prior to rendering an item or service that is usually covered by Medicare but may not be covered in this particular case.  (See the Medicare Claims Processing Manual, chapter 30 for ABN policy and 40.24 of this chapter for a description of the difference between an ABN and a private contract.)  The ABN notifies the beneficiary that Medi care will likely deny the claim and prompts the beneficiary to choose whether or not he/she will accept liability for the full cost of the services if Medicare does not pay.  The beneficiary also indicates on the ABN whether or not a claim should be submit ted to Medicare.  Providers and suppliers must follow the beneficiarys directive for claim submission as indicated on the ABN.  Providers and suppliers will not violate the mandatory claim submission rules of 1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiarys written request on an ABN.  Where a valid ABN is given and a claim is submitted, subsequent denial of the claim relieves the non -opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.  Opt-out physicians and practitioners must not use ABNs, because they use private contracts for any item or service that is, or may be, covered by Medicare (except for emergency or urgent care services (see 40.28)).  Where a physician/practitioner, or other supplier, fails to submit a claim to Medicare on behalf of a beneficiary for a covered Part B service within 1 year of providing the service, or knowingly and willfully charges a beneficiary more than the applicable charge limits on a repeated basis, he/she/it may be subject to civil monetary penalties under 1848(g)(1) and/or 1848(g)(3) of the Act.  Congress enacted these requirements for the protection of all Part B beneficiaries.  Application of these requirements cannot be negotiated between a physician/practitioner or other supplier and the beneficiary except where a physician/practitioner is eligible to opt out of Medicare under 40.4 and the remaining requirements of 40.1 - 40.38 are met.  Agreements with Medicare beneficiaries that are not authorized as described in these manual sections and that purport to waive the claims filin g or charge limitations requirements, or other Medicare requirements, have no legal force and effect.  For example, an agreement between a physician/practitioner, or other supplier and a beneficiary to exclude services from Medicare coverage, or to excuse mandatory assignment requirements applicable to certain practitioners, is ineffective.   The A/B MAC (B) will refer such cases to the OIG.   This subsection does not apply to noncovered charges.  40.1 - Private Contracts Between Beneficiaries and Physicians/Practitioners  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  Section 1802 of the Act, as amended by 4507 of the BBA of 1997 and 106 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10), permits a physician/practitioner to opt-out of Medicare and enter into private contracts with Medicare beneficiaries if specific requirements of this instruction are met.   40.2 - General Rules of Private Contracts  (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16)  The following rules apply to physicians/practitioners who opt-out of Medicare:   A physician/practitioner may enter into  one or more private contracts with Medicare beneficiaries for the purpose of furnishing items or services that would otherwise be covered by Medicare (provided the conditions in 40.1 are met).    A physician/practitioner who enters into at least one private contract with a Medicare beneficiary (under the conditions of 40.1) and who submits one or more affidavits in accordance with 40.9, opts-out of Medicare unless the opt-out is terminated early according to 40.35  or unless the physician/practitioner fails to maintain opt-out.  (See 40.11 .)   Valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every 2 years. If physicians and practitioners who file affidavits effective on or after June 16, 2015, do not want their opt-out to automatically renew at the end of a 2 year opt-out period, they may cancel the renewal by notifying all contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.  Valid opt-out affidavits signed before June 16, 2015, will expire 2 years after the effective date of the opt -out.  If physicians and practitioners that filed affidavits effective before June 16, 2015, want to extend their opt-out, they must submit a renewal affidavit within 30 days after the current opt -out period expires to all contractors with which they would have filed claims absent the opt -out.