evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
 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.
(Medicare Benefit Policy Manual)
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).
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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);
(Medicare Benefit Policy Manual)
 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
(Medicare Benefit Policy Manual)
 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.
(Medicare Benefit Policy Manual)
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.   90 - Routine Services and Appliances  (Rev. 186, Issued: 04- 16-14, Effective: 01- 01 01, Implementation: 05 -12-14)  Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye re fractions by whatever practitioner and for whatever purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered.   The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies.  The routine physical checkup exclusion does not appl y to the following services (as noted in section 42 CFR 411.15(a)(1)):    Screening mammography,   Colorectal cancer screening tests,   Screening pelvic exams,   Prostate cancer screening tests,   Glaucoma screening exams,   Ultrasound screening for abdomi nal aortic aneurysms (AAA),   cardiovascular disease screening tests,   diabetes screening tests,   screening electrocardiogram,   Initial preventive physical examinations,   Annual wellness visits providing personalized prevention plan services, and  Additional preventive services that meet the criteria specified in 42 CFR 410.64.
(Medicare Benefit Policy Manual)
If the claim is for a diagnostic test or examination performed solely for the purpose of establishing a claim under title IV of Public Law 91 -173, Black Lung Benefits, the  service is not covered under Medicare and the claimant should be advised to contact their Social Security office regarding the filing of a claim for reimbursement under the Black Lung program.  The exclusions apply to eyeglasses or contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors.  The exclusions do not apply to physicians services (and services incident to a physicians service) performed in conjunction with an eye disease, as for example, glaucoma or cataracts, or to post -surgical prosthetic lenses which are customarily used during convalescence from eye surgery in which the lens of the eye was removed, or to permanent prosthetic lenses required by an individua l lacking the organic lens of the eye, whether by surgical removal or congenital disease.  Such prosthetic lens is a replacement for an internal body organ -  the lens of the eye.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Ot her Health Services, 120).   Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.   A.  Im munizations   Vaccinations or inoculations are excluded as immunizations unless they are either:    Directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment, tetanus antitoxin or booster vaccine , botulin antitoxin, antivenin sera, or immune globulin. (In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered.); or    Specifically cove red by statute, as described in the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50 .4.4.2.  B.  Antigens
(Medicare Benefit Policy Manual)
 Specifically cove red by statute, as described in the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50 .4.4.2.  B.  Antigens   Prior to the Omnibus Reconciliation Act of 1980, a physician who prepared an antigen for a patient could not be reimbursed for that service unless the physician also administered the antigen to the patient.  Effective January 1, 1981, payment may be made for a reasonable supply of antigens that have been prepared for a particular patient even though they have  not been administered to the patient by the same physician who prepared them if:    The antigens are prepared by a physician who is a doctor of medicine or osteopathy, and   The physician who prepared the antigens has examined the patient and has determined  a plan of treatment and a dosage regimen.  A reasonable supply of antigens is considered to be not more than a 12 -month supply of antigens that has been prepared for a particular patient at any one time.  The purpose of the reasonable supply limitation is  to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.4.4.1 )  100 - Hearing Aids and Auditory Implants  (Rev. 39; Issued: 11- 10-05; Effective: 11- 10-05; Implementation:  12 -12-05)  Section 1862(a)(7)  of the Social Security Act states that no payment may be made under part A or part B for any expenses incurred for items or services where such expenses are for . . . hearing aids or examinations therefore. . . .  This policy is further reiterated at  42 CFR 411.15(d)  which specifically states that hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded f rom coverage.   Hearing aids are amplifying devices that compensate for impaired hearing.  Hearing aids include air conduction devices that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound.  They also incl ude bone conduction devices that provide mechanical energy to the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.