(Medicare Benefit Policy Manual)

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.   Ambulance companies which charge membership fees generally do not charge additional fees for services covered under the membership plan, although they may charge for certain other services (e.g., additional trips or mileage).  Services furnished by such ambulance companies including services for which prepayment is made under the membership plan, are considered to be services for which there is a legal obligation to pay.  Therefore, such services are reimbursable provided the ambulance company bills all third party payers.  Membership fees and insurance premiums are not incurred expenses under Medicare (see the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 10) and are not reimbursable.   50 - Items and Servic es Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments  (Rev. 1, 10- 01-03) A3-3153, HO -260.3, B3- 2309  The law contains three separate exclusions applicable to items and services furnished, paid for or authorize d by governmental entities.  In general, payment may not be made for items and services:    Furnished by a provider (Governmental or non governmental) or other person at public expense pursuant to an authorization issued by a Federal agency ( 50.1 );   Furnished by a provider of services or agency of the Federal government ( 50.2 ); and   Paid for directly or indirectly by a Federal, State, or local governmental entity (50.3).  The A/B MAC (A) or (B)  applies each of these exclusions separately, i.e., benefits are excluded where any one of the exclusions applies.  50.1 - Items and Services Which a Non -Federal Provider Furnishes Pursuant to an Authorization Issued by a Federal Agency (Rev. 1, 10- 01-03) A3-3153.1, HO -260.3.B, B3- 2309.2   50.1.1 - Veterans Administration (VA) Authorized Services  (Rev. 1, 10- 01-03) A3-3153.1.A, B3 -2309.2, A3- 3153.1.E, HO -260.3.B   Generally, an authorization issued by the Veterans Administration (VA) binds the VA to pay in full for the items and services provided.  No payment is made under Medicare for such authorized services.  NOTE:  Medicare can reimburse veterans for (or credit toward Medicare deductible or coinsurance amounts) VA copayment amounts charged for VA authorized services furnished by non- VA sources.   Medicare does not pay for any item or service rendered by a non -Federal provider pursuant to an authorization issued by a Federal agency, under the terms of which the Federal government agrees to pay for the services.   The VA may authorize non- Federal providers or private physicians or other suppliers to render services at Federal expense.  For example, the VA may pay for treatment of veterans in non- VA hospitals for servi ce connected disabilities and, in certain circumstances, for nonservice -connected disabilities, provided the VA has given prior authorization for the services.  The VA may also agree to pay for emergency services furnished a veteran who appears at a hospit al without prior authorization, provided a notification of the veterans admission and a request for authorization to provide care at VA expense is submitted to the VA within 72 hours after the admission.  As a general rule, the VA does not authorize inpat ient services at non -VA facilities for treatment of nonservice -connected conditions.  Accordingly, the A/B MAC (A) should receive few, if any, requests for reimbursement for a VA copayment for treatment in a non-VA provider.  If a beneficiary requests reim bursement for the amount of the VA copayment, the beneficiary must submit to the A/B MAC (A) , along with their request, VA Form 10 -9014, Statement of Charges for Medical Care.  These requests will be handled on an ad hoc basis. For further guidance contact :  Centers for Medicare & Medicaid Services  Center for Medicare Management  Provider Billing Group 7500 Security Boulevard  Baltimore, Maryland 21244- 1850  The VA may authorize up to six months of care in non- VA SNFs for veterans requiring such care after t ransfer from a VA hospital.  Services furnished pursuant to a VA authorization do not count against the 100 days of extended care benefits available in a benefit period.  Where a veteran remains in a SNF until VA benefits are exhausted, extended care benef its could begin under Medicare.  Such benefits begin with the first day after the VA benefits are exhausted, provided a physician certifies that the individual still requires skilled nursing care on a continuing basis for a condition for which the patient received inpatient hospital services or which arose while the patient was still being treated in the facility for such a condition.  The 3- day qualifying hospital stay and 30-day transfer requirements of the law must be met as of the time of entrance to th e facility.   Where an authorization from the VA was not given to the party rendering the services, Medicare payment is not precluded even though the individual might have been entitled to have payment made by the VA had they requested the authorization.  A lso, Medicare secondary benefits may be payable where the VA authorizes fewer days than the total number of covered days in the stay.   Generally it is advantageous for Medicare beneficiaries who are veterans to have items and services paid for by the VA where possible, since in most cases the VA has no deductible or coinsurance requirements.  Also, services paid for in full by the VA do not count against the individuals maximum number of benefit days or visits available in a Medicare benefit period.   However, the VA may charge veterans copayments for treatment of nonservice -connected conditions (during periods of 90 days duration within a period of 365 days) if a veterans income exceeds a specified amount ( 38 CFR Part 17).  The VA may charge the beneficiary a copayment for physician/supplier and outpatient services.  The amount of the copayment is equal to 20 percent of the estimated average cost (during the calendar year in which the services are furnis hed) of an outpatient visit in a VA facility.  The VA determines the estimated average cost. The beneficiary pays the copayment amount directly  to the VA, i.e., the VA does not reduce its payments to physicians/suppliers or for outpatient services.  The total amount of a veterans copayment obligation for all services received (inpatient and outpatient, authorized or furnished directly by the VA) during any 90- day period within the 365- day period cannot exceed the amount of the inpatient Medicare deductible  in effect on the first day of the 365- day period.  Medicare pays secondary benefits to the beneficiary for VA copayment amounts in accordance with 50.1.4 .  The charges for the following services are credited to the Medicare deductibles, on the basis of Medicare fee schedule or allowable amounts, even though the Federal Agency (VA) has not yet paid for them.   Charges for services that exceed the VA copayment;    Services rendered in a non -VA facility that are not authorized b y the VA; or    Services rendered after VA benefits are exhausted in a non -VA facility.   Crediting of VA payments to Medicare deductibles is handled in the same manner as the crediting of employer group health plan payments.  See Pub 100- 05, the Medicare Secondary Payer (MSP) Manual, Chapter 3, for billing and Chapter 5 for payment instructions.  Medicare can pay for such services where neither the physician/supplier nor beneficiary has claimed benefits from the VA.   Medicare may also pay for (covered) servic es for which the VA does not make any payment.  For example, if a veteran is authorized fee basis care at VA expense for a service connected back injury, and receives treatment for a different condition for which the VA does not pay, Medicare can pay for  the (covered) services that are not reimbursable by the VA.   50.1.2 - Medicare Secondary Payment Where VA Authorizes Fewer Days Than Total Number of Covered Days in the Stay  (Rev. 1, 10- 01-03) A3-3153.1.C, HO -260.3.B   The Medicare secondary payment is the  lower of:    The gross amount payable by Medicare for all covered days in the stay (without regard to deductible or coinsurance) minus the amount paid by the VA for Medicare covered services, or    The gross amount payable by Medicare (without regard to deductible or coinsurance) minus any applicable Medicare deductible or coinsurance.   EXAMPLE:   The VA authorizes payment for 4 days of a 7- day stay.  Charges for the 4 days total $2,350.  The VA reimburses the hospital that amount.  The gross amount payabl e by Medicare (unreduced by deductible and coinsurance) for the 7 -day stay is $3,350.  The beneficiarys Part A deductible has not been met.  The Medicare secondary payment is determined by subtracting the VA payment from the gross amount payable by Medicare:  $3,350 -  $2,350 = $1,000.  Medicare pays $1,000, which is less than the gross amount payable by Medicare minus the Medicare deductible ($3,350 -  $812 = $2,538).  The beneficiarys Part A deductible is met by the VA payment.   50.1.3 - Effect of VA Paym ents on Medicare Deductible and Utilization  (Rev. 1, 10- 01-03) A3-3153.1.D, HO -260.3.B   Where an authorization issued by the VA binds the VA to pay in full for the items and services, no payment may be made under Medicare.  When the VA pays in full, the services do not count against benefit maximums, e.g., the 90 days of inpatient hospital services or the 60 -day lifetime reserve.  Charges which would be reimbursable by Medicare except for the fact that the VA paid in full for authorized services may be credited to the Medicare deductibles.   When the VA authorizes fewer days than the total number of covered days in the stay, Medicare utilization is determined as follows:    Divide the actual Medicare payment by the amount Medicare would have paid for covered ch arges as primary payer (i.e., the gross amount payable by Medicare for all covered days in the stay reduced by applicable Medicare deductible and coinsurance).   Multiply this percentage by the number of covered days in the stay.   A partial day resulting fr om this calculation is not charged as a full day if it is less than .5 of a day, but is charged as a full day if it is .5 or more of a day.   EXAMPLE:   The following is the same facts as presented in example in 50.1.2.  The amount Medicare would pay, as a primary payer, is $2,538 ($3,350 -  $812 deductible).  Utilization is determined as follows:  $1,000  $2,538 =. 39 X 7 days = 2.75, rounded to 3 days .  When the VA pays an amount for Medicare covered services that is equal to, or less than, the deductible and coinsurance that would apply if Medicare were the primary payer, utilization is not  reduced.   50.1.4 - VA Fee Basis Card (Rev. 1, 10- 01-03) B3-2309.2  1.  General   One method the VA uses to authorize physician services is to issue the veteran a fee basis ID card (formally designated the VA Outpatient Medical Treatment Information Card).  This card is issued to certain veterans with a service  connected disability, as well as certain other veterans who require medical services for an extended period when VA and other Federal health care facilities are not capable of furnishing economical care, or, because of geographical inaccessibility, are no t capable of furnishing the care or services required.  The card constitutes an agreement by the VA to pay up to a specified monthly dollar amount for treatment of specific disabilities or for any condition specified on the face of the card.  The veteran i s not restricted in choice of physician nor does the physician selected by the veteran have to inform the VA in advance that they will be treating the veteran. (The physicians are not participating physicians in the VA program nor does the VA have an expre ss assignment procedure.)