(Medicare Benefit Policy Manual)

(c) Claim Is for Reimbursement of VA Copayment Amounts or  Crediting of Medicare Deductible  Beneficiaries must attach to the Medicare claim form a copy of VA form 10 -9014 (Statement of Charges for Medical Care) showing the VA copayment amount for authorized services, when requesting Medicare payment toward that amount or in order to have their Part B deductible credited.   50.1.5 - Services Authorized by Indian Health Service  (Rev. 1, 10- 01-03) A3-3153.1.B, HO -260.3A.2 B.3- 2309.3   The Division of Indian Health of the United States Public Health Service authorizes private physicians and privately owned hospitals and nursing homes to provide treatment to Indians and their dependents under contractual arrangements with the Division of Indian Health.  In the case of such contract health services to Indians and their dependents entitled under the Indian Health Service (IHS) program and Medicare, Medicare is the primary payer and the IHS the secondary payer.   50.2 - Items and Services Furnished by Federal Provider of Services or Federal Agency  (Rev. 1, 10- 01-03) A3-3153.2, HO- 260.3.A, B3- 2309.1   Generally, Federal providers are excluded from participation in the Medicare program.  However, Federal hospitals, like other nonparticipating hospitals, may be paid for emergency inpatient and outpatient hospital services.  Additi onally, payment is precluded for items and services rendered by a federally operated nonprovider, e.g., Veterans Administration clinics.  A provider or other facility acquired by the Department of Housing and Urban Development (DHUD) in the administration of an FHA mortgage insurance program is not considered to be a Federal provider or agency and this exclusion is not applicable to services furnished by such facilities.  The law provides exceptions to this exclusion which permits the following categories o f Federal providers to participate in Medicare:    Hospitals and SNFs of Indian Health Service; and    A Federal provider which is determined to be providing services to the public generally as a community institution or agency.  VA hospitals which have sharing agreements with non- VA participating hospitals under which the VA hospitals furnish end- stage renal disease (ESRD) services to nonveterans may be considered community hospitals with respect to any otherwise covered service rendered to ESRD beneficiaries.   This exception does not apply to Federal clinics or other Federal health facilities which are not providers of services as defined in the Medicare law, i.e., which are not hospitals, SNFs, HHAs or CORFs.  The CMS is responsible for processing claims for services furnished directly by Federal providers.  If the A/B MAC (A)  were to receive a request for Medicare reimbursement of such services it would forward the request to:   Centers for Medicare & Medicaid Services  Office of Financial Management  P.O. Box  17255 Baltimore, Maryland 21203- 7255  NOTE:   The VA copayment provisions mentioned in 50.1.1 also applies to inpatient services furnished in a VA hospital.  Should the A/B MAC (A)  receive a request for Medicare reimbursement of VA copayment amounts for emergency services furnished by VA hospitals, it would refer the request to CMS.  50.3 - Items or Services Paid for by Governmental Entity  (Rev. 1, 10- 01-03) A3-3153.3, HO -260.3.C, B3- 2309.4   Medicare payment may not be made for items or services paid for directly or indirectly by a Federal, State or local governmental entity.  However, the law specifies that this exclusion does not prohibit payment for:    Items or services furnished under a health benefits or insur ance plan established for employees of the governmental entity;    Items or services furnished under one of the titles of the Social Security Act (such as medical assistance under title XIX); or    Rural health clinic services.   50.3.1 - Application of Exclus ion to State and Local Government Providers  (Rev. 1, 10- 01-03) A3-3153.3.A, HO -260.3.C   Except for the two categories of facilities referred to below, payment may not be made for items and services which a State or local government facility furnishes free of charge, i.e., without expectation of payment from any source and without regard to the individuals ability to pay.  A facility which reduces or waives its charges for patients unable to pay, or charges patients only to the extent of their Medicare and other health insurance coverage, is not viewed as furnishing free services and may therefore receive program payment.  Medicare regulations permit payment to the following two categories of governmental providers even though they furnish services free of c harge:    Payment may be made for items and services furnished in or by a participating State or local Government hospital, including a psychiatric or tuberculosis hospital, which serves the general community.  A psychiatric hospital to which patients convic ted of crimes are committed involuntarily is considered to be serving the general community if State law provides for voluntary commitment to the institution.  However, payment may not be made for services furnished in or by State or local hospitals, which  serve only a special category of the population, but do not serve the general community, e.g., prison hospitals.   Payment may be made for items and services paid for by a State or local governmental entity and furnished an individual as a means of control ling infectious diseases or because the individual is medically indigent.   50.3.2 - Application of Exclusion to Nongovernmental Providers, Physicians and Suppliers  (Rev. 1, 10- 01-03) A3-3153.3.B, HO -260.3.D, B3- 2309.4   Payment may not be made for items or services furnished by a nongovernmental provider, physician or supplier if the charges have been paid for by a government program other than Medicare, or if the provider, physician, or supplier intends to look to anothe r government program for payment, unless the payment by the other program is limited to the Medicare deductible and coinsurance amounts, as it is for certain individuals covered under TRICARE/CHAMPVA.  (See 50.4).  The m ere fact that a nongovernmental provider receives government financing does not mean that the items and services it furnishes are considered paid for by a governmental entity.  However, if a clinic receives government financing earmarked for particular services to patients (e.g., in the form of a research grant), Medicare may not pay for the same services.   If an individual has the option of receiving care free of charge at a government provider or care which is not free at a nongovernment provider, and the  individual, chooses the latter, Medicare payment may be made for the care at the nongovernment provider.  However, items and services authorized by a Federal agency (for example, by the VA at a nongovernmental hospital) are excluded.  (See 50.3.3, below.)   50.3.3 - Examples of Application of Government Entity Exclusion  (Rev. 122, Issued: 04- 09-10, Effective/Implementation Date: 07 -09-10)  The following paragraphs explain the application of the governmental entity exclusion to various situations involving services rendered by governmental and non governmental facilities:  1.  State Veterans Homes   Many State governments operate veterans homes and hospitals.  These institutions are generally open only to veterans and certain dependents of veterans, and include domiciliary, hospital, infirmary, and/or nursing home type facilities.  These institutions are financed primarily from State funds; in addition, most receive nominal per diem payments from the VA for domiciliary care, hospital care, or nursing home type  care for each veteran who would also qualify for admission to a VA hospital or domiciliary.   When such a participating institution charges its residents and patients to the extent of their ability to pay, or seeks payment from available sources other than Medicare, benefits are payable for covered items and services furnished to Medicare beneficiaries.  However, if it is the policy of the institution to admit and treat a veteran without charge simply because the individual is a veteran, or because the condition is service -connected, payment would be precluded under title XVIII.   Per diem amounts paid by the VA to State veterans homes on behalf of those patients who are otherwise eligible for care in a VA facility may be credited towards any deductible, coinsurance, or noncovered amounts required to be paid by the patient. However, if a State veterans home collects amounts from the VA in excess of the applicable deductible and coinsurance, the A/B MAC (A) reduces the Medicare payment to the extent of such pay ments.   2.  State and Local Psychiatric Hospitals   In general, payment may be made under Medicare for covered services furnished without charge by State or local psychiatric hospitals which serve the general community.  (See 50.3.1.) However, payment may not be made for services furnished without charge to individuals who have been committed under a penal statute (e.g., defective delinquents, persons found not guilty by reason of insanit y, and persons incompetent to stand trial).  For Medicare purposes such individuals are prisoners, as defined in subsection 3, and may have services paid by Medicare only under the exceptional circumstances described there.   A psychiatric hospital to whi ch patients convicted of crimes are committed is considered to be serving the general community if State law also provides for voluntary admissions to the institution.   3.  Prisoners   The regulation at 42 CFR 411.4(b) states:   Individuals who are in cust ody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule.   Moreover, 72 FR 47405 states further that the   definition of custody is in accordance with how custody is defined by Federal courts for purposes of the habeas corpus protections of the Constitution. For example, the term custody is not limited solely to physical confinement. (Sanders v. Freeman, 221F.3d 846, 850- 851 (6th Cir. 2000).)  Individuals on parole, probation, bail, or supervised release may be in custody.   42 CFR 411.4(b) goes on to describe the special conditions that must be met in order for Medicare to make payment for individuals who are in custody, 42 CFR 411.4(b) states:   Payment may be made for services furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met:   1.   State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody, and   2.   The State or local government entity enforces the requirement to pay by billing all such individuals , whether or not covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts."   The CMS presumes that a state or local gover nment that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and services unless the State can demonstrate to the A/B MAC (A)s, (B)s, or (HHH)s, or DME MACs satisfaction, in c onsultation with the RO, that:    State or local law requires that individuals in custody repay the cost of the services.    The State or local government entity enforces the requirement to pay by billing and seeking collection from all individuals in custody with the same legal status (e.g., not guilty by reason of insanity), whether insured or uninsured, and by pursuing collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.  This includes coll ection of any Medicare deductible and coinsurance amounts and the cost of items and services not covered by Medicare.   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.