(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 16 - General Exclusions From Coverage   Table of Contents (Rev. 1 98, 11-06-14)  Transmittals for Chapter 16   10 - General Exclusions from Coverage  20 - Services Not Reasonable and Necessary  30 - Foot Care  40 - No Legal Obligation to Pay for or Provide Services  40.1 - Indigence  40.2  Provider, Physician, or Supplier Bills Only Insured Patients  40.3 - Medicare Patient Has Other Health Coverage  40.4 - Items Covered Under Warranty  40.5 - Members of Religious Orders  40.6 - Am bulance Services  50 - Items and Services Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments  50.1 - Items and Services Which a Non -Federal Provider Furnishes Pursuant to an Authorization Issued by a Federal Agency  50.1.1 - Veterans Administration (VA) Authorized Services  50.1.2 - Medicare Secondary Payment Where VA Authorizes Fewer Day s Than Total Number of Covered Days in the Stay  50.1.3 - Effect of VA Payments on Medicare Deductible and Utilization  50.1.4 - VA Fee Basis Card"  50.1.5 - Services Authorized by Indian Health Service  50.2 - Items and Services Furnished by Federal Provider of Services or Federal Agency  50.3 - Items or Services Paid for by Governmental Entity  50.3.1 - Application of Exclusion to State and Local Government Providers  50.3.2 - Application of Exclusion to Nongovernmental Providers, Physicians and Suppliers  50.3.3 - Examples of Application of Government Entity Exclusion  50.4 -  TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration)  50.5 -  Active Duty Members of Uniform ed Services  60 - Services Not Provided Within United States  70 - Services Resulting from War  80 - Personal Comfort Items  90 - Routine Services and Appliances  100 -  Hearing Aids and Auditory  Implants  110 -  Custodial Care  110.1 -  Custodial Care Under a Hospice Program  120 -  Cosmetic Surgery  130 -  Charges Imposed by Immediate Relatives of the Patient or Members of the Patients Household 140 -  Dental Services Exclusion  150 -  Services Reimbursable Under Automobile, No Fault,  Any Liability Insurance or Workers Compensation 170 -  Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider  180 -  Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare   10 - General Exclusions f rom Coverage  (Rev.  198, Issued: 11- 06-14, Effective: 01- 01-15, Implementation: 01- 05-15)  No payment can be made under either the hospital insurance or supplementary medical insurance program for certain items and services, when the following conditions exist:    Not reasonable and necessary (20);    No legal obligation to pay for or provide (40);    Paid for by a governmental entity (50);    Not provided within United States (60 );    Resulting from war (70);    Personal comfort (80);    Routine services and appliances (90 );    Custodial care (110 );    Cosmetic surgery (120);    Charges by immediate relatives or members of household (130 );    Dental services ( 140);    Paid or expected to be paid under workers compensation ( 150);    Non-physician services provided to a hospital inpatient that were not provided directly or arranged for by the hospital (170);    Services Related to and Required as a Result of Services Which are not Covered Under Medicare ( 180);    Excluded foot care services and supportive devices for feet (30); or ,    Excluded investigational devices (See Chapter 14).   20 - Services Not Reasonable and Necessary  (Rev. 1, 10- 01-03) A3-3151, HO -260.1, B3- 2303, AB -00-52 - 6/00   Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a  malformed body member are not covered, e.g., payment cannot be made for the rental of a special hospital bed to be used by the patient in their home unless it was a reasonable and necessary part of the patients treatment.  See also 80 .  A health care item or service for the purpose of causing, or assisting to cause, the death of any individual (assisted suicide) is not covered.  This prohibition does not apply to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing death.   30 - Foot Care  (Rev. 1, 10- 01-03)  Some foot care is excluded and some is covered. A description of both is in Chapter 15, 290.  40 - No Legal Obligation to Pay for or Provide Services (Rev. 1, 10- 01-03) A3-3152, HO -260.2, B3- 2306  Program payment may not be made for items or services which neither the beneficiary nor any other person or organization has a legal obligation to pay for or provide.  This exclusion applies where items and services are furnished gratuitously without regard to the beneficiarys ability to pay and without expectation of payment from any source, such as free x -rays or immunizations provided by health organizations.  However, Medicare reimbursement is not precluded merely because a provider, physician, or supplier waives the charge in the case of a particular patient or group or class of patients, as the waiver of charges for some patients does not impair the right to charge others, including Medicare patients.  The determinative factor in applying this exclusion is the reason the particular individual is not charged.   The following sections illustrate the applicability of this exclusion to various situations involving services other than those paid for directly or indirectly by a governmental entity.  (For a discussion of the latter, see 50.)  40.1 - Indigence  (Rev. 1, 10- 01-03) A3-3152.A, H O-260.2.A   This exclusion does not apply where items and services are furnished to an indigent individual without charge because of their inability to pay, if the provider, physician, or supplier bills other patients to the extent that they are able to pay .  40.2 - Provider, Physician, or Supplier Bills Only Insured Patients  (Rev. 1, 10- 01-03) A3-3152.B, HO -260.2.B   Some providers, physicians, and suppliers waive their charges for individuals of limited means, but they also expect to be paid where the patie nt has insurance which covers the items or services they furnish.  In such a situation, because it is clear that a patient would be charged if insured, a legal obligation to pay exists and benefits are payable for services rendered to patients with medical  insurance if the provider, physician, or supplier customarily bills all insured patients -  not just Medicare patients -  even though non-insured patients are not charged.   Individuals with conditions which are the subject of a research project may receive treatment financed by a private research foundation.  The foundation may establish its own clinic to study certain diseases or it may make grants to various other organizations.  In most cases, the patient is not expected to pay for treatment out -of-pocket , but if the patient has insurance, the parties expect that the insurer will pay for the services.  In this situation, a legal obligation is considered to exist in the case of a Medicare patient even though other patients may not have insurance and are not  charged.   40.3 - Medicare Patient Has Other Health Coverage  (Rev. 1, 10- 01-03) A3-3152.C, HO -260.2.C   Payment is not precluded under Medicare if the patient is covered by another health insurance plan or program, which is obligated to provide or pay for the same services.   However, Medicare does not pay until after the other payer has paid in the following situations:   Services covered by automobile medical or no -fault insurance;    Services rendered during a specified period of up to 30 months to individua ls eligible or entitled solely on the basis of end stage renal disease (ESRD) who are insured under an employer group health plan;    Services rendered to individuals age 65 or over and spouses age 65 or over who are insured under an employer group health pl an by virtue of current employment status;    Services rendered to individuals under age 65 entitled to Medicare based on disability and have large group health plan coverage based on the individuals current employment status or the current employment statu s of a family member; and    Services covered by workers compensation.   In these cases, the other plan pays primary benefits and if the other plan does not pay the entire bill, secondary Medicare benefits may be payable.  Medicare is also secondary to the extent that a liability insurer has paid for services.   See the Medicare Secondary Payment (MSP) Manual, Pub. 100- 05.  40.4 - Items Covered Under Warranty  (Rev. 1, 10- 01-03) A3-3152.D, HO -260.2.D   When defective equipment or a defective medical device is replaced under a warranty, hospital or other provider services rendered by parties other than the warrantor are covered despite the warrantors liability.  However, see the Medicare MSP Manual (CMS Pub. 100- 05) for requirements for recovery under the liabi lity insurance provisions.   With respect to payment for the device itself under cost reimbursement, the following rules apply:    If equipment or a device is replaced free of charge by the warrantor, no program payment may be made, since there was no charge involved.   If replacement equipment or device from another manufacturer had to be substituted because the replacement offered under the warranty was not acceptable to the beneficiary or the beneficiarys physician, payment may be made for the replaced devi ce.   If the warrantor supplied the replaced equipment or device, but some charge or a pro rata payment was imposed, program payment may be made for the partial payment imposed for the device furnished by the warrantor.    If an acceptable replacement could h ave been obtained free of charge under a warranty but the provider chose to purchase one instead, payment cannot be made for the purchased device under the prudent buyer rules.  (See Provider Reimbursement Manual, Part 1, 2103.)    If an acceptable replacem ent could have been purchased at a reduced price under a warranty but the full price was paid to the original manufacturer or a new replacement was purchased from a different manufacturer or other source, coverage is limited to the amount that would have been paid under the warranty.   While payments to a hospital for inpatient services under the prospective payment system (PPS) are not reduced to reflect collections under warranty provisions for medical devices, cost -based reimbursed hospitals and exempt units are subject to the prudent buyer rules.   40.5 - Members of Religious Orders  (Rev. 1, 10- 01-03) A3-3152.E, HO -260.2.E   A legal obligation to pay exists where a religious order either pays for or furnishes services to members of the order.  Although medi cal services furnished in such a setting would not ordinarily be expressed in terms of a legal obligation, the order has an obligation to care for its members who have rendered life -long services, similar to that existing under an employers prepayment pla n.  Thus, payment may be made for such services whether they are furnished by the order itself or by independent sources that customarily charge for their services.   40.6 - Ambulance Services  (Rev. 1, 10- 01-03) B3-2306  There are numerous methods of financing ambulance companies.  For example, some volunteer organizations do not charge the patient or any other person but ask the recipient of services for a donation to help offset the cost of the service.  Although the recipients may be under considera ble moral and social pressure to donate, they are not required to do so, and there is no enforceable legal obligation on the part of the individual or anyone else to pay for the services. Thus, Medicare benefits would not be payable.  However, services of volunteer ambulance corps are not categorically excluded.  Many such companies regularly charge for their services and Medicare covers these services.   Some ambulance companies provide services without charge to residents of specific geographical areas but  charge non -residents to the extent they are able to pay (e.g., through private health insurance).  Under those circumstances, the free services provided the residents would be excluded from coverage, while the services furnished non-residents would be cov ered.