evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
Home health services are services provided by a home health agency or by others under arrangements with such an agency.  A home health agency is a public agency or private organization which is primarily engaged in providing skilled nursing and other therapeutic services.  Where applicable the agency must be licensed under State or local law, or be approved by the State or local licensing agency as meeting the licensing standards.  Examples of home health agencies are visiting nurse associations, official health agencies, and hospital -based home care programs.  To participate in the health insurance program, a home health agency must meet certain other requirements included in the law as well as health and safety conditions prescribed by the Secretary of the Department of Health and Human Services.  It may not qualify under hospital insurance, however, if it is primarily engaged in the treatment of mental diseases; such an agency may qualify only under supplementary medical insurance.   Home health services are usually furnished on a visiting basis in a place of residence used as the individual's home.  However, outpatient services in a hospital, SNF, or rehabilitation center are covered home health services, if arranged for by a home health agency, when equipment is required that cannot be made available in the patient's home.  The services of an intern or resident -in-training are covered if the agency has an affiliation with or is under common control of a hospital providing such medical services and the agency bills for such services.   Prior to July 1, 1981, home health services under hospital insurance included up to 100 home health visits, after the beginning of one benefit period and before the beginning of the next.  The visits must have been furnished to a patient within 1 year of his/her most recent discharge from a hospital where he was an inpatient for at least 3 consecutive calendar days (counting the day of admission, but not the day of discharge).  If, after his/her hospitalization, he had a covered stay in a SNF, the 1 year during which the patient may receive home health services began with the discharge from the SNF.  A plan of treatment must have been established within 14 days after the hospital or SNF discharge.  Home health services were also provided under supplementary medical insurance where the 100- visit limit under Part A was exceeded.
(Medicare General Information, Eligibility, and Entitlement)
Effective July 1, 1981, the 100- visit limitation under Parts A and B, and the prior inpatient stay requirement under Part A were eliminated.  In addition, a person could qualify for home health services based on his or her need for skilled nursing services on an intermittent basis, physical therapy, speech- language pathology services, or occupational therapy.  Effective December 1, 1981, occupational therapy was eliminated as a basis for entitlement to home health services. However, if a person has otherwise qualified for home health services because of the need for skilled nursing care, physical therapy or speech- language pathology services, the patient's eligibility for home health services may be extended solely on the basis of the continuing need for occupational therapy.   Effective January 1, 1998, the first 100 visits must be paid under Part A if the beneficiary is entitled under Part A, and the remainder of the visits may be paid under Part B.  10.3 - Supplementary Medical Insurance (Part B) - A Brief Description  (Rev. 12425, Issued: 12- 21-23, Effective: 01- 01-24, Implementation: 01- 02-24)    To obtain SMI, an eligible individual must enroll during an enrollment period and pay the required premiums.  An individual is eligible to enroll if they are entitled to HI or are 65 years of age and a citizen or resident alien who meets certain residence requirements.  SMI provides for payment to participating providers for furnishing covered services after a yearly cash deductible is met.  The voluntary medical insurance plan is designed to supplement the basic hospital insurance coverage.  It provides coverage for home health visits not available under hospital insurance (e.g., no Part A entitlement or visits after the first 100 visits) and for medical and other health services.  Payment may not be made under Part B for any service that may be paid under Part A.  However, where payment is not possible under Part A (e.g., no Part A entitlement or benefits are exhausted) payment may be made under Part B if the service is covered.    Subject to coverage and limitations described in the Benefit Policy Publication, the following services are covered under Part B.     Physicians' services;
(Medicare General Information, Eligibility, and Entitlement)
Subject to coverage and limitations described in the Benefit Policy Publication, the following services are covered under Part B.     Physicians' services;     Services and supplies (including drugs and biologicals which are not usually self -administered by the patient) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;     Hospital services (including drugs and biologicals which are not usually self -administered by the patient) incident to physicians' services rendered to outpatients and partial hospitalization or intensive outpatient  services incident to such services;     Diagnostic services which are:  (i) furnished to an individual as an outpatient by a hospital or by others under arrangements with them made by a hospital, and (ii) ordinarily furnished by such hospital (or by others under such arrangements) to its outpatients for the purpose of diagnostic study;     Outpatient physical therapy services, occupational therapy services, and speech- language pathology services;     Rural health clinic services and Federally qualified health center services;     Home dialysis supplies and equipment, self -care home dialysis support services, and institutional dialysis services and supplies;     Antigens (subject to quantity limitations prescribed in regulations by the Secretary) prepared by a physician, as defined in section 1861(r)(1) of the Act, for a particular patient, including antigens so prepared which are forwarded to another qualified person (including a rural health clinic) for administration to such patient, from time to time, by or under the supervision of another such physician;     Services furnished pursuant to a contract under section 1876 of the Act to a member of an eligible organization by a physician assistant or by a nurse practitioner and such services and supplies furnished as an incident to his/her service to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician's service; and, services furnished pursuant to a risk- sharing contract under section 1876(g) of the Act to a member of an eligible organization by a clinical psychologist (as defined by the Secretary) or by a clinical social worker, and such services and supplies furnished as an incident to such clinical psychologist's services or clinical social worker's services to such a member as would otherwise be covered under this part if furnished by a physician or as an incident to a physician's service;
(Medicare General Information, Eligibility, and Entitlement)
 Blood clotting factors, for hemophilia patients competent to use such factors to control bleeding without medical or other supervision, and items related to the administration of such factors, subject to utilization controls deemed necessary by the Secretary for the efficient use of such factors;     Prescription drugs used in immunosuppressive therapy furnished to an individual who receives an organ transplant for which payment is made under this title;     Services which would be physicians' services if furnished by a physician and which are performed by a physician assistant under the supervision of a physician and which the physician assistant is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as incident to such services as would be covered if furnished incident to a physician's professional service; and but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.     Services which would be physicians' services if furnished by a physician and which are performed by a nurse practitioner or clinical nurse specialist working in collaboration with a physician which the nurse practitioner or clinical nurse specialist is legally authorized to perform by the State in which the services are performed, and such services and supplies furnished as an incident to such services as would be covered if furnished incident to a physician's professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services;     Certified nurse -midwife services;     Qualified psychologist services;     Clinical social worker services;     Erythropoietin for dialysis patients competent to use such drug without medical or other supervision with respect to the administration of such drug, subject to methods and standards established by the Secretary by regulation for the safe and effective use of such drug, and items related to the administration of such drug;     Prostate cancer screening tests;     An oral drug (which is approved by the Federal Food and Drug Administration) prescribed for use as an anticancer chemotherapeutic agent for a given indication, and containing an active ingredient (or ingredients), which is the same indication and active ingredient (or ingredients) as a drug which the A/B MAC (B) determines would be covered if the drug could not be self -administered;     Colorectal cancer screening tests;     Diabetes outpatient self -management training services;
(Medicare General Information, Eligibility, and Entitlement)
 Colorectal cancer screening tests;     Diabetes outpatient self -management training services;     An oral drug (which is approved by the Federal Food and Drug Administration) prescribed for use as an acute anti -emetic used as part of an anticancer chemotherapeutic regimen if the drug is administered by a physician (or as prescribed by a physician) -- (i) for use immediately before, at, or within 48 hours after the time of the administration of the anticancer chemotherapeutic agent; and (ii) as a full replacement for the anti -emetic therapy which would otherwise be administered intravenously;     Screening for glaucoma (as defined in subsection (uu)) for individuals determined to be at high risk for glaucoma, individuals with a family history of glaucoma and individuals with diabetes;     Medical nutrition therapy services in the case of a beneficiary with diabetes or a renal disease who -- (i) has not received diabetes outpatient self -management training services within a time period determined by the Secretary; (ii) is not receiving maintenance dialysis for which payment is made under section 1881 of the Act; and (iii) meets such other criteria determined by the Secretary after consideration of protocols established by dietitian or nutrition professional organizations;     Diagnostic X -ray tests (including tests under the supervision of a physician, furnished in a place of residence used as the patient's home, if the performance of such tests meets such conditions relating to health and safety as the Secretary may find necessary and including diagnostic mammography if conducted by a facility that has a certificate (or provisional certificate) issued under section 354 of the Public Health Service Act), diagnostic laboratory tests, and other diagnostic tests; X -ray, radium, and radioactive isotope therapy, including materials and services of technicians;     Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations; Durable medical equipment;     Ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations;
(Medicare General Information, Eligibility, and Entitlement)
 Ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulations;     Prosthetic and orthotic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices, and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens;     Leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient's physical condition;     Vaccines: (1) pneumococcal vaccine and its administration and, subject to section 4071(b) of the Omnibus Budget Reconciliation Act of 1987, (2) influenza vaccine and its administration; and (3) hepatitis B vaccine and its administration, furnished to an individual who is at high or intermediate risk of contracting hepatitis B;    NOTE:   A charge separate from the ESRD composite rate will be recognized and paid for administration of the vaccine to ESRD patients.    NOTE:   For Medicare program purposes, the hepatitis B vaccine may be administered upon the order of a doctor of medicine or osteopathy by home health agencies, SNFs, renal dialysis facilities (RDFs), hospital outpatient departments, persons recognized under the "incident to physicians' services" provision of law, and, of course, doctors of medicine and osteopathy.     Services of a certified registered nurse anesthetist;
(Medicare General Information, Eligibility, and Entitlement)
 Services of a certified registered nurse anesthetist;     Subject to section 4072(e) of the Omnibus Budget Reconciliation Act of 1987, extra -depth shoes with inserts or custom molded shoes with inserts for an individual with diabetes, if -- (1) the physician who is managing the individual's diabetic condition (a) documents that the individual has peripheral neuropathy with evidence of callus formation, a history of pre -ulcerative calluses, a history of previous ulceration, foot deformity, or previous amputation, or poor circulation, and (b) certifies that the individual needs such shoes under a comprehensive plan of care related to the individual's diabetic condition; (2) the particular type of shoes are prescribed by a podiatrist or other qualified physician (as established by the Secretary); and (3) the shoes are fitted and furnished by a podiatrist or other qualified individual (such as a pedorthist or orthotist, as established by the Secretary) who is not the physician described in (1) above (unless the Secretary finds that the physician is the only such qualified individual in the area);     Screening mammography;     Screening pap smear and screening pelvic exam; and      Bone mass measurement.     No diagnostic tests performed in any laboratory, including a laboratory that is part of a rural health clinic, or a hospital (which, for purposes of this sentence, means an  institution considered a hospital for purposes of section 1814(d)) of the Act shall be included unless such laboratory-     1. Is situated in any State in which State or applicable local law provides for licensing of establishments of this nature, (1) is licensed pursuant to such law, or (2) is approved, by the agency of such State or locality responsible for licensing establishments of this nature, as meeting the standards established for such licensing;    2. Meets the certification requirements under section 353 of the Public Health Service Act; and     3. Meets such other conditions relating to the health and safety of individuals with respect to whom such tests are performed as the Secretary may find necessary.
(Medicare General Information, Eligibility, and Entitlement)
2. Meets the certification requirements under section 353 of the Public Health Service Act; and     3. Meets such other conditions relating to the health and safety of individuals with respect to whom such tests are performed as the Secretary may find necessary.    There shall be excluded from the diagnostic services specified any item or service which would not be included if it were furnished to an inpatient of a hospital.  None of the items and services referred to in the preceding paragraphs of this subsection which are furnished to a patient of an institution which meets the definition of a hospital for purposes of section 1814(d) of the Act shall be included unless such other conditions are met as the Secretary may find necessary relating to health and safety of individuals with respect to whom such items and services are furnished.   10.4 - Basis for Payment  (Rev. 1, 09- 11-02)  (See Claims Processing, Pub 100- 04 for a description of the basis for payment for the various services.)   20 - Administration of the Medicare Program - Introduction  (Rev. 1, 09- 11-02)  The conduct of the program has been delegated by the Secretary of the Department of Health and Human Services to the Administrator of the Centers for Medicare & Medicaid Services (CMS).  Congress has also provided substantial administrative roles for the States and for voluntary insurance organizations in recognition of their experience in the health care and insurance fields.   The law does not permit the Federal Government to exercise supervision or control over the practice of medicine, the manner in which medical services are provided, and the administration or operation of medical facilities.  The patient is free to choose any qualified institution, agency, or person offering him/her services.  The responsibility for treatment and the control of care remains with the individual's physician and the hospital or other facility or agency furnishing services.  The individual may keep or obtain any other health insurance he/she desires including the choice to enroll in a Medicare+Choice plan.  More information about Medicare+Choice plans is in the Medicare Managed Care Manual.  20.1 - Financing the Program  (Rev. 1, 09-11-02)
(Medicare General Information, Eligibility, and Entitlement)
20.1 - Financing the Program  (Rev. 1, 09-11-02)   Part A is financed through separate payroll contributions paid by employees, employers, and self-employed persons.  The proceeds are deposited to the account of the Federal Hospital Insurance Trust Fund, which is used only for hospital insurance benefits and administrative expenses.  Federal employees and State and local employees who do not pay the full FICA tax must pay the HI portion; they are not eligible for monthly Social Security or railroad retirement benefits.  The cost of providing Part A benefits to other persons who are not Social Security or railroad retirement beneficiaries is met by appropriations to the Federal Hospital Insurance Trust Fund from general revenues or through premium payments.  Part B is financed by monthly premiums of those who voluntarily enroll in the program and by the Federal Government which makes contributions from general revenues.  All premiums and Government contributions are deposited in a separate account known as the Federal Supplementary Medical Trust Fund.  Money from this fund is used only to pay for Part B benefits and administrative expenses.  20.2 - Discrimination Prohibited  (Rev. 28; Issued:  08-12- 05; Effective/Implementation:  09 -12-05)  Participating providers of Part A services under the supplementary medical insurance program (e.g., hospitals, SNFs, HHAs, hospices, outpatient physical therapy, comprehensive outpatient rehabilitation facilities (CORFs), occupational therapy and speech -language pathology providers, and renal dialysis facilities) must comply with the requirements of title VI of the Civil Rights Act of 1964.  Under the provisions of that Act, a participating provider is prohibited from making a distinction on the grounds of race, color, or national origin, in the treatment of patients, the use of equipment, other facilities, and the assignment of personnel to provide services.  The DHHS is responsible for investigating complaints of noncompliance.  20.3 - Fraud and Abuse - General  (Rev. 1, 09-11-02)
(Medicare General Information, Eligibility, and Entitlement)
Providers and suppliers have an obligation, under law, to conform to the requirements of the Medicare program.  Fraud and abuse committed against the program may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution, fines, and, in some instances, imprisonment.  In addition, there is also a range of administrative sanctions (such as exclusion from participation in the program) and civil monetary penalties that may be imposed when facts and circumstances warrant such action.  Following are definitions and examples of fraud and abuse.  These definitions and examples give a better understanding of the types of practices that are forbidden, under law, in the Medicare program.   20.3.1 - Definition and Examples of Fraud  (Rev. 1, 09- 11-02)  Fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.  These acts may be committed either for the person's own benefit or for the benefit of some other party.  In order to prove that fraud has been committed against the Government, it is necessary to prove that fraudulent acts were performed knowingly, willfully, and intentionally.   Examples of fraud include, but are not limited to, the following:    Billing for services that were not furnished and/or supplies not provided.  This includes billing Medicare for appointments that the patient failed to keep;    Altering claims forms and/or receipts in order to receive a higher payment amount;    Duplicating billings that includes billing both the Medicare program and the beneficiary, Medicaid, or some other insurer in an effort to receive payment greater than allowed;    Offering, paying, soliciting, or receiving bribes, kickbacks, or rebates, directly or indirectly, in cash or in kind, in order to induce referrals of patients or the purchase of goods or services that may be paid for by the Medicare program;    Falsely representing the nature of the services furnished.  This encompasses describing a noncovered service in a misleading way that makes it appear as if a covered service was actually furnished;    Billing a person who has Medicare coverage for services provided to another person not eligible for Medicare coverage; and    Using another person's Medicare card to obtain medical care.   20.3.2 - Definition and Examples of Abuse  (Rev. 1, 09- 11-02)