evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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.)   When the charges for the services exceed the specified monthly amount routinely allowed by the VA, the VA may allow an additional amount if the physician justifies the need for the additional cost. If justified, the VA will authorize an increase in the monthly dollar limitation for a specific period of time.  The VA may approve charges for services exceeding the specified monthly amount retroactively if they were of the type that would have been approved had they been submitted in advance.   2.  VA Fee Basis Payment Is Payment in Full
(Medicare Benefit Policy Manual)
2.  VA Fee Basis Payment Is Payment in Full   When a physician accepts veterans as patients and bills the VA , the physician must accept the VAs usual and customary charge determination as payment in full.  Neither the patient nor any other party can be charged an additional amount.  Except for the VA copayment (see subsection 4(b)), Medicare cannot make payment on an assigned or unassigned basis when the physicians bill exceeds the amount the VA paid a physician  who has accepted the Fee Basis card.  However, as indicated in subsection 4(a), Medicare can pay for services that are not reimbursable by the VA.  Therefore, the mere existence of a Y trailer code indicating that the beneficiary has a VA fee card (as  discussed in subsection 5 ) is not sufficient to deny Medicare benefits.  See subsection 4(a) for secondary Medicare benefits where the veteran bills the VA, and the VA reimburses the beneficiary or physician less than the Medi care allowable amount.   3.  Crediting Part B Deductible   Payments made by the VA for otherwise covered services are credited to the beneficiarys Part B deductible.  (See subsection 5(c).)  4.  Secondary Benefits   (a) Veteran Bills the VA   Where the physician does not accept the fee basis card (i.e., bills the veteran directly) the veteran may file a claim with the VA.  The VA may either reimburse the beneficiary for out -of-pocket costs or pay the physician based on a claim fil ed by the beneficiary.  If the VA payment to the beneficiary or physician based on a claim filed by the beneficiary is less than the Medicare fee schedule or allowable amount for the services, Medicare can pay secondary benefits to supplement the VA paymen t, provided the beneficiary submits a copy of the VAs explanation of benefits which accompanies the VA payment.
(Medicare Benefit Policy Manual)
The VA explanation of benefits generally consists of a computer -generated notice, which looks much like a punch card.  It contains the beneficiarys name and social security number, the physicians or suppliers name, the month of service, and the amount paid.  (The VA plans to add the day of service to the notice.)  The VA sends this notice to the party that receives the payment (i.e., t he beneficiary or the physician/supplier).  In some cases, the VA may also send a letter containing more detailed information.  If the A/B MAC (B) cannot determine from the VA notice the amount the VA paid for particular services, it asks the physician or supplier to help it match up the VA payment with specific services for which Medicare has been billed.  If the A/B MAC (B) is unable to obtain the help it needs from the physician or supplier, it make reasonable assumptions about the relationship between t he VA payment and the services which have been billed to Medicare based on the information available to it.   The Medicare secondary benefit amount, where the VA payment to the beneficiary or physician is less than the allowable amount, is the lower of the following:    The Medicare allowable amount minus applicable Medicare deductible and coinsurance amounts; or    The Medicare allowable amount minus the VA payment.   EXAMPLE:  An individual who is authorized by the VA to receive physician services for treatmen t of a nonservice -connected condition is issued a fee basis card.  The individual receives treatment from a physician who charges $135.  The physician does not accept the fee basis card.  The individual bills the VA directly.  The VA pays the individual $82 ($96 fee basis rate minus $14 outpatient copayment).  The Medicare allowable amount for the service is $115.  The individuals unmet Part B deductible is $75.  The Medicare secondary benefit is the lower of:    The Medicare allowable amount minus applicabl e deductible and coinsurance amounts:   $115 -  $75 = $40 X .80 = $32, or    The Medicare allowable amount minus the VA payment:   $115 -  $82 = $33.
(Medicare Benefit Policy Manual)
$115 -  $75 = $40 X .80 = $32, or    The Medicare allowable amount minus the VA payment:   $115 -  $82 = $33.   The A/B MAC (B) pays $32, the lower of $32 or $33.  The beneficiarys Part B deductible is considered met by the VA payment.   (b) Physician Bills the VA; VA Bills Beneficiary for Copayment   If a physician accepts the fee basis card and bills the VA, the VA payment is considered payment in full.  If the VA bills the beneficiary a copayment amount for authorized ph ysician/supplier services that are covered by Medicare in the absence of the VA authorization, the A/B MAC (B) pays a secondary benefit to the beneficiary consisting of the lower of the VA copayment amount or the amount Medicare would pay in the absence of  VA coverage (Medicare allowable amount minus applicable deductible and coinsurance amounts).   EXAMPLE:   A physician accepts fee basis reimbursement for services rendered.  The charges for the services are $96.  The VA fee basis rate is $78.  The VA pays t he physician $78 and charges the beneficiary a $14 copayment.  The beneficiary claims Medicare reimbursement for the VA copayment amount.  The Medicare allowable amount for the services is $83.  The individuals unmet Part B deductible is $75.  The Medicar e secondary benefit is the lower of:    Amount payable by Medicare in the absence of VA coverage:   $83 -  $75 = $8 X .8 = $6.40, or    Individuals VA copayment obligation: $14.   The A/B MAC (B) pays $6.40.  The beneficiarys deductible is credited with $75. If  the beneficiarys Part B deductible had been met previously, the Medicare secondary payment would be $14, the lower of:    $66.40 ($83 X .8), or    $14.
(Medicare Benefit Policy Manual)
 $66.40 ($83 X .8), or    $14.  NOTE:   Medicare may pay for covered outpatient emergency services furnished by a VA hospital if there is a charge for the services.  Medicares payment is subject to applicable Part B Medicare deductible and coinsurance provisions.  Accordingly, there is no Med icare payment until the Part B deductible is met.  However, any charges to the beneficiary for covered VA hospital outpatient emergency services are credited to the Medicare Part B deductible.  The CMS, OMB, Division of Accounting, which is responsible for  processing claims for emergency services by Federal providers, will ensure, in these cases, that pertinent data is entered into the beneficiarys Health Insurance Master Beneficiary Record.   5.  Procedure
(Medicare Benefit Policy Manual)
5.  Procedure  (a) Claim Is for Primary Medicare Benefits   When the A/B MAC (B) receives a Y trailer code (code 3) or a code 36, (type code 3), automatic notice from the Health Insurance Master File (which is sent in instances where a Medicare beneficiary also has a VA fee basis card), it follows the instructions in the Medicare Secondary Payer (MSP) Manual, Chapter 5, Contractor Prepayment Processing Requirements, 20.3.1.  It contacts the physician or supplier to ascertain whether a claim has been, or will be submitted to the VA based on an authorization of the VA o r based on the fee basis card.  If the physician responds that no claim has been or will be submitted to the VA, the A/B MAC (B) pays the Medicare claim in the usual manner.  If the physician or supplier indicates that a claim has been or will be submitted  to the VA, the A/B MAC (B) denies the Medicare claim.  If the physician fails to respond to the A/B MAC (B)s inquiry within 30 days, the A/B MAC (B) denies the claim if the physician has accepted assignment  on the grounds that the physician refuses to fu rnish information necessary to determine the proper Medicare payment.  (The assignment agreement prohibits the physician from charging the beneficiary in these cases because the basis for denial is failure to furnish information, not noncoverage of service s.)  In unassigned cases, if the physician fails to respond to the A/B MAC (B)s inquiry within 30 days, the A/B MAC (B) pays the Medicare claim in the usual manner.  In accordance with a CMS -VA agreement, no contacts are to be made with the beneficiary, u nless the beneficiary has submitted a claim for secondary Medicare benefits.  Ordinarily, the A/B MAC (B) does not contact the VA for information concerning actual or potential VA payments; but if a VA facility offers to share such information with it, e.g ., information about payments to beneficiaries or physicians or about VA authorized services to beneficiaries, the A/B MAC (B) may work out arrangements with the facility to receive such information on a periodic basis or on request.   (b) Claim Is for Seco ndary Medicare Benefits
(Medicare Benefit Policy Manual)
(b) Claim Is for Seco ndary Medicare Benefits   If the information on the claim indicates that the VA has already paid benefits for the services, but has not paid all of the charges, the Medicare A/B MAC (B)  pays Medicare secondary benefits in accordance with subsection 4(a) provided the VA claim was filed by the beneficiary .  If the beneficiary submits the VAs computer generated notice, the A/B MAC (B) assumes that the beneficiary filed the VA claim and pays secondary benefits.  If it is unclear wh ether the physician or beneficiary submitted the VA notification, the A/B MAC (B) assumes that, in unassigned cases, the beneficiary filed the VA claim and the A/B MAC (B) pays secondary benefits.  In assigned cases, the A/B MAC (B) asks the physician whet her the physician or the beneficiary filed the VA claim.  Also, when it is clear that the physician submitted the computer -generated notice, the A/B MAC (B) asks the physician (on both assigned and unassigned claims) whether the physician or the beneficiar y filed the claim with the VA (since in either case the VA sends the notice to the physician who receives the VA payment).   If the physician does not respond within 30 days, the A/B MAC (B) denies benefits, in assigned cases, because of the physicians ref usal to furnish information necessary to determine the proper Medicare payment.  (The assignment agreement prohibits the physician from charging the beneficiary in these cases because the basis for denial is failure to furnish information, not noncoverage of services.)  In unassigned cases, if the physician does not respond within 30 days, the A/B MAC (B) assumes that the beneficiary filed the VA claim and pays secondary benefits to the beneficiary.   (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.
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
 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
(Medicare Benefit Policy Manual)
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).
(Medicare Benefit Policy Manual)
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.