(Medicare Benefit Policy Manual)

NOTE:   The A/B MAC (A), (B), or (HHH), or DME MAC will require evidence that routine collection efforts include the filing of lawsuits to  obtain liens against individuals assets outside the prison and income derived from non -prison sources.    The State or local entity documents its case with copies of regulations, manual instructions, directives, etc., spelling out the rules and procedures for billing and collecting amounts paid for prisoners medical expenses.  As a rule, the A/B MAC (A), (B), or (HHH), or DME MAC  will inspect a representative sample of cases in which prisoners have been billed and payment pursued, randomly selected from b oth Medicare and non- Medicare eligible.  The existence of cases in which the State or local entity did not actually pursue collection, even though there is no indication that the effort would have been unproductive, indicates that the requirement to pay is  not enforced.   The CMS maintains a file of incarcerated beneficiaries, obtained from SSA, that is used to edit claims.   Providers and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions described ab ove indicate this fact with the use of a modifier (for A/B MAC (B)  processed claims) or condition code (for A/B MAC (A)  processed claims). Otherwise the claims are denied.   4.  Health Department Outpatient Clinics   Services rendered free of charge by State and local health department outpatient clinics are not covered unless the services are rendered because of the individuals indigence or as a means of controlling infectious diseases.  Thus, services rendered by ci ty-operated clinics for the poor and clinics for the detection and treatment of such illnesses as venereal disease and tuberculosis are not  excluded from Medicare coverage.   5.  Vocational Rehabilitation (VR) Agencies   Under the vocational rehabilitation ( VR) programs of the various States, vocational training and services, including hospital and medical care, are provided to handicapped persons who qualify under State law.  These programs are financed in part by a Federal matching fund program set up under  the Vocational Rehabilitation Act.   When items or services are furnished by a State VR agency, title XVIII benefits are payable if the agency charges all clients for its services or makes services available without cost only to medically indigent individuals. If a rehabilitation agency has paid for items and services furnished by nonproviders (e.g., physicians services and prosthetic appliances), it may claim the Part B payment due the beneficiary if the latter has authorized it to do so.  The procedure i s similar to that provided for State welfare agencies; the State vocational rehabilitation agency function is comparable to that of a State welfare agency in relation to a welfare recipient.   50.4 - TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration)  (Rev. 1, 10- 01-03) A3-3153.3.D, HO -260.3.F   1.  General   TRICARE and CHAMPVA are similar programs administered by the Department of Defense, except that the Veterans Administration determines the eligibility of persons seeking t o establish entitlement to CHAMPVA coverage.  TRICARE provides benefits for health care services furnished by civilian providers, physicians, and suppliers to retired members of the Uniformed Services and to spouses and children of active duty, retired, an d deceased members.  The term Uniformed Services includes the Army, Navy, Air Force, Marine Corps, Coast Guard, and the Commissioned Corps of the U.S. Public Health Service and of the National Oceanic and Atmospheric Administration.  CHAMPVA provides sim ilar benefits for spouses and children of veterans who are entitled to VA permanent and total disability benefits and to widows and children of veterans who died of service -connected disabilities.   The governmental entity exclusion does not preclude Medica re payment for items or services furnished to a beneficiary who is also eligible for TRICARE/CHAMPVA benefit payments for the same services. Medicare is the primary payer for such items and services, and TRICARE/CHAMPVA is a supplementary payer.  (See subs ection 3, below.)   2.  Effect of Medicare Eligibility on TRICARE/CHAMPVA Entitlement   TRICARE/CHAMPVA beneficiaries, other than dependents of active duty members, lose their entitlement to TRICARE/CHAMPVA if they qualify for Medicare Part A on any basis an d do not enroll in Medicare Part B (effective October 1, 2001).   NOTE:  TRICARE beneficiaries that turned age 65 prior to April 1, 2001 are not required to purchase Medicare Part B in order to retain their TRICARE Pharmacy benefits.  However, all TRICARE i ndividuals entitled to Medicare Part A must be enrolled in Medicare Part B to receive the rest of their TRICARE benefit.   Individuals who are eligible for Medicare Part B benefits only, do not lose their entitlement to TRICARE/CHAMPVA benefits.  If a Medicare beneficiary, who has lost entitlement to CHAMPVA upon becoming entitled to Part A of Medicare, thereafter exhausts any  Part A benefits, the individual can again be entitled to CHAMPVA.  Once the individual re -attains CHAMPVA benefits, the individual will not lose them by virtue of later again becoming eligible for Medicare Part A benefits.  There is no similar provision f or TRICARE which enables an individual to re -attain TRICARE eligibility after exhausting Medicare Part A benefits.  A/B MACs (A) and (B)  will direct questions concerning this provision to the CHAMPVA Center.   3.  Medicare -TRICARE/CHAMPVA Relationship   If a TRICARE/CHAMPVA beneficiary also has Medicare coverage, TRICARE/ CHAMPVA reduces its liability in all cases by the amount payable by Medicare, i.e., Medicare is the primary payer and TRICARE/CHAMPVA supplements Medicare by paying the Medicare deductible and coinsurance amounts and portions of the bill not covered by Medicare.  Thus, dually entitled individuals may be reimbursed up to 100 percent of expenses for items and services covered by both programs.   TRICARE/CHAMPVA has established policies and proce dures which provide for (a) the identification of claimants who have coverage under both TRICARE/CHAMPVA and Medicare and (b) the detection of duplicate payments under both programs. If TRICARE/CHAMPVA inadvertently pays amounts which duplicate Medicare pa yments for the same items or services, TRICARE/CHAMPVA will take steps to recover the incorrect TRICARE/CHAMPVA payments.   50.5 - Active Duty Members of Uniformed Services  (Rev. 1, 10- 01-03) A3-3153.3.E, HO -260.3.G   In limited circumstances, active duty me mbers of the Uniformed Services may have care in civilian facilities paid for by the Army, Navy, Air Force, Marine Corps, or other appropriate uniformed service.  Except for emergency services, prior approval is generally required before such payment can b e made.  Services furnished pursuant to such approval and services paid for or expected to be paid for by the Uniformed Services are not reimbursable under Medicare.   60 - Services Not Provided Within United States  (Rev. 102; Issued:  02- 13-09; Effective/I mplementation Date:  03 -13-09)  Items and services furnished outside the United States are excluded from coverage except for the following services, and certain services rendered on board a ship:    Emergency inpatient hospital services where the emergency o ccurred:   o While the beneficiary was physically present in the United States; or   o In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State.  See Pub. 100- 04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures.    Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United States, if the hospital was closer to, or substantially more accessible from, the beneficiarys United States residence than the nearest participating United States hospital which was adequately equipped to deal with and available to provide treatment of the illness or injury (see Pub. 100- 04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures);    Physician and ambulance services furnished in connection with a covered foreign hospitalization.  Program pay ment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States (see Pub. 100- 04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.1 for  a description of claims processing procedures);    Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States terri torial waters.  Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of Un ited States registry (see Pub. 100- 04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.7 for a description of claims processing procedures); and   The term United States means the 50 States, the District of Columb ia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States.   A hospital that is  not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government.  Payment may not be made for any item provided or delivered to the beneficiary outside the United States, even though the beneficiary may have contracted to purchase the item while they were within the United States or purchased the item from an American firm.   Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States.  For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.   Under the Railroad Retirement Act, payment is made to Qualified Railroad Retirement beneficiaries (QRRBs) by the RRB for covered hos pital services furnished in Canadian hospitals as well as in the U.S.  Physician and ambulance services are not covered by the Railroad Retirement Act; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in conne ction with Canadian hospitalization, RRB processes the Part B claim. In such cases the RRB determines:    Whether the requirements are met for the inpatient services; and    Whether the physician and/or ambulance services were furnished in connection with the services.   Services for an individual who has elected religious nonmedical health care status may be covered if the above requirements are met but this revokes the religious nonmedical health care institution election.   70 - Services Resulting from War  (Rev. 1, 10- 01-03) A3-3155, HO -260.5, B3- 2315  Items and services which are required as a result of war, or of an act of war, occurring after the effective date of the patients current entitlement date are not covered.   80 - Personal Comfort Items (Rev. 1, 10- 01-03) A3-3156, HO -260.6, B3- 2318  Items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.   Charges for special items requested by the patient such as radio, televi sion, telephone, and air conditioner, and beauty and barber services are excluded from coverage.  The patient may be charged for such a service if they requested it with knowledge that they will be charged.  To avoid misunderstanding and disputes, the provider informs the individual upon request for such an item or service that there is a specified charge (not exceeding the customary charge).  Thereafter, the provider may not charge the patient more for the item or service than the charge specified.  A prov ider may not require a beneficiary to request noncovered items or services as a condition of admission or of continued stay.   Basic personal services such as simple barber and beautician services (e.g., shaves, haircuts, shampoos, and simple hair sets) whi ch patients need and cannot perform for themselves may be viewed as ordinary patient care when furnished by a long -stay institution.  Such services are covered costs reimbursable under Part A when included in the flat rate charge and provided routinely wit hout charge to the patient by an SNF or by a general psychiatric or tuberculosis hospital.  The services are maintenance of at least a minimum level of personal hygiene, decency, and presentability  items  essential to the well-being of the patient and of ot her patients who must associate with the patient.  However, under the personal comfort exclusion, more elaborate services, such as professional manicures, hair styling, etc., are excluded even when furnished routinely and without special charge.