evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
Medicare no -payment bills submitted by a SNF result in Medicare program payment determinations (i.e., denials).  Therefore, such no- payment bills trigger the appropriate presumptions.  This also applies in any State where the Medicaid program utilizes no-payment bills which lead to Medicaid program payment determinations.  If a SNF erroneously fails to submit a Medicare claim (albeit a no -pay claim) when Medicare rules require such submission, A/B MACs (A) request a SNF to submit one.  Once the no- pay bill is submitted and denied, the applicable presumption (other than presumption 7) is triggered.  If a patient is moving from a SNF level of care to a non- SNF level of care i n a facility certified to provide SNF care, occurrence code 22 (date active care ended) is used to signify the beginning of the no- pay period on the bill and trigger the appropriate presumptions.  Where the presumptions are rebuttable (i.e., 5 through 7), rebuttal showings are permitted at both A/B MAC (A) determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the status of a prior SNF stay is made at the time that an inpatient claim is submitted and/or at the reconsideration level).  A/B MACs (A) evaluate rebuttal documentation even if the presumption being rebutted was triggered by a Medicaid denial.   This special rule for determining whether a beneficiary in a SNF is an inpatient for benefit period purposes is applicable in all cases where a prior SNF stay affects benefit period status, not only when a beneficiary is in exhausted or copay status and is  seeking to renew a benefit period.  The rule has equal application where it results in the beneficiary starting a new benefit period and paying a new deductible without receiving an increase in the amount of Medicare benefits paid.   20 - Supplementary Medical Insurance (SMI) (Part B)  (Rev. 1, 09- 11-02)  Supplementary Medical Insurance is described in the following subsections.  20.1 - Supplementary Medical Insurance Incurred Expenses  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
Supplementary Medical Insurance is described in the following subsections.  20.1 - Supplementary Medical Insurance Incurred Expenses  (Rev. 1, 09- 11-02)  The SMI plan includes coverage for expenses incurred for the services described in Chapter 1, 10.3:   Payment may not be made under Part B for services furnished an individual entitled to have payment made for those services under Part A, e.g., if the expenses incurred were to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of request for payment or physician certification.  20.2 - Part B Annual Deductible  (Rev. 12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  In each calendar year, a cash deductible must be satisfied before payment can be made under SMI. (See 20.4 of this chapter for exceptions.)   Calendar Year  Deductible  1966  1972  $50 1973  1981  $60 1982  1990  $75 1991  2004  $100  2005  $110  2006  $124  2007  $131  2008  $135  2009  $135  2010  $155  2011  $162  2012  $140  2013  $147  2014  $147  2015  $147  2016  $166  2017  $183  2018  $183  2019  $185  2020  $198  2021  $203  2022  $233  2023  $226  2024  $240   Expenses count toward the deductible on the basis of incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non- covered expenses do not count toward the deductible. Even though an individual is not entitled to Part B benefits for t he entire calendar year (i.e., insurance coverage begins after the first month of a year or the individual dies before the last month of the year), he or she is still subject to the full deductible for that year. Medical expenses incurred in the portion of  the year preceding entitlement to medical insurance are not credited toward the deductible.   The date of service generally determines when expenses were incurred, but expenses are allocated to the deductible in the order in which the bills are received. Services not subject to the deductible cannot be used to satisfy the deductible.   Pro Rata Amounts   Pro Rata Amounts
(Medicare General Information, Eligibility, and Entitlement)
Pro Rata Amounts   Pro Rata Amounts   First Month  Second Month  2012  $100.20  $39.80  2013  $103.95  $43.05  2014  $114.99  $32.01  2015  $114.99  $32.01  2016  $118.86  $47.14  2017  $125.73  $57.27  2018   $126.88  $56.12  2019  $133.57  $51.43  2020  $140.46  $57.54  2021  $145.31  $57.69  2022  $150.66  $82.34  2023  $154.95  $71.05  2024  $161.71  $78.29   The Part B deductible is split into pro rata amounts. The purpose of the pro rata amount is to provide beneficiaries who are enrolled in managed care plans the benefit of assuming they have paid their deductible as if they were not enrolled in a managed care plan. The pro rata amount does not apply only to just the first tw o months of the year but rather for the number of months after first enrollment in a managed care plan that is necessary to cover the Part B deductible. Each year starts the deduction for the pro rata amount over again.   20.3 - Part B Coinsurance  (Rev. 1, 09- 11-02)  After the deductible has been satisfied, coinsurance of 20 percent is usually applicable.   For providers and suppliers that bill A/B MAC(A) or (HHH), the 20 percent may be based on the allowed amount, billed charges, or a preset rate per service (APC), depending upon the type of service.  See Claims Processing instructions for a description of coinsurance calculation for each benefit type.   Physicians and other suppliers will be paid 80 percent of allowed amount under the fee schedule amounts or in some instances reasonable charges incurred during the balance of the calendar year.  The patient is responsible for a coinsurance amount equal to 20 percent of the fee schedule amounts or reasonable charges for the items and services. (See 20.4 of this chapter for exceptions.)   20.4 - Exceptions to Annual Deductible and Coinsurance  (Rev. 11, Issued: 10- 22-04, Effective: 11 -22-04, Implementation: 11- 22-04)  There is no deductible for screening mammography effective for services January 1, 1998 and later.
(Medicare General Information, Eligibility, and Entitlement)
There is no deductible for screening mammography effective for services January 1, 1998 and later.   Neither the annual deductible nor the 20 percent coinsurance apply with respect to:    Parts A and B home health services, except that there is a coinsurance of 20 percent of the payment amount for supplies, drugs, DME and prosthetics /orthotics furnished as a home health benefit;   Clinical diagnostic laboratory tests (including specimen collection fees) performed or supervised by a physician, laboratory, or other entity paid on an assigned basis;   Pneumococcal vaccine and its administration;   Influenza vaccine and its administration; and   Services or items denied as medically unnecessary.   NOTE:  Services which are not subject to the deductible cannot be used to satisfy the deductible.   20.4.1 - Applications of Deductible and Coinsurance in Liability and Indemnification Situations  (Rev. 12, Issued:  10- 22-04, Effective:  04 -01-05, Implementation:  04- 04-05)  Under 1879 of the Act, a beneficiary is not responsible for payment of the Part B deductible or coinsurance for items or services that are neither reasonable and necessary to diagnose or treat the illness or injury, nor to improve the functioning of a malf ormed body member.  If the provider knew, or should have known, that Medicare considered such services medically unnecessary, but failed to inform the beneficiary before furnishing them, the provider is held liable for their cost.  If the beneficiary made payment for such items or services, he/she can be indemnified for them.   In most cases, however, funds can be collected while awaiting the outcome of review of a demand bill for institutional services -- See Publication 100- 04, Chapter 1, 60.3, See 60.3.1 in the same chapter for specific information on limitations on collecting funds from beneficiaries in SNF Part A stays.  In general, see Chapter 30 of that publication for information on limitation of liability.   20.5 - Blood Deductibles (Part A and Part B)  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
20.5 - Blood Deductibles (Part A and Part B)  (Rev. 1, 09- 11-02)  Program payment may not be made for the first 3 pints of whole blood or equivalent units of packed red cells received under Part A and Part B combined in a calendar year.  However, blood processing (e.g., administration, storage) is not subject to the deductible.   The blood deductibles are in addition to any other applicable deductible and coinsurance amounts for which the patient is responsible.  The deductible applies only to the first 3 pints of blood furnished in a calendar year, even if more than one provider furnished blood.   20.5.1 - Part A Blood Deductible  (Rev. 1, 09- 11-02)  Blood must be furnished on a Medicare covered day in a hospital or SNF to be counted under Part A.  Blood furnished to an inpatient after benefits exhausted or before entitlement is not counted toward the combined deductible.  Blood furnished during a lifetime extension election period is counted toward the combined A/B 3 pint total.  20.5.2 - Part B Blood Deductible  (Rev. 1, 09- 11-02)  Blood is furnished on an outpatient basis or is subject to the Part B blood deductible and is counted toward the combined limit.  It should be noted that payment for blood may be made to the hospital under Part B only for blood furnished in an outpatient s etting.  Blood is not covered for inpatient Part B services.   20.5.3 - Items Subject to Blood Deductibles  (Rev. 18, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)
(Medicare General Information, Eligibility, and Entitlement)
20.5.3 - Items Subject to Blood Deductibles  (Rev. 18, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  The blood deductibles apply only to whole blood and packed red cells.  The term whole blood means human blood from which none of the liquid or cellular components have been removed.  Where packed red cells are furnished, a unit of packed red cells is consi dered equivalent to a pint of whole blood.  Other components of blood such as platelets, fibrinogen, plasma, gamma globulin, and serum albumin are not subject to the blood deductible.  However, these components of blood are covered as biologicals.  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, 231 regarding billing for blood and blood products under the Hospital Outpatient Prospective Payment System (OPPS).   20.5.4 - Obligations of the Beneficiary to Pay for or Replace Deductible Blood  (Rev. 1, 09- 11-02)  A provider may charge the beneficiary or a third party its customary charge for whole blood or units of packed red cells which are subject to either the Part A or Part B blood deductible, unless the individual, another person, or a blood bank replaces the blood or arranges to have it replaced.   20.5.4.1 - Replacement of Blood  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
20.5.4.1 - Replacement of Blood  (Rev. 1, 09- 11-02)  For replacement purposes, a pint of whole blood is considered equivalent to a unit of packed red cells.  A deductible pint of whole blood or unit of packed red cells is considered replaced when a medically acceptable pint or unit is given or offered to the  provider or, at the provider's request, to its blood supplier.  Accordingly, where an individual or a blood bank offers blood as a replacement for a deductible pint or unit furnished a Medicare beneficiary, the provider may not charge the beneficiary for the blood, whether or not the provider or its blood supplier accepts the replacement offer.  Thus a provider may not charge a beneficiary merely because it is the policy of t he provider or its blood supplier not to accept blood from a particular source which has offered to replace blood on behalf of the beneficiary.  However, a provider would not be barred from charging a beneficiary for deductible blood, if there is a reasona ble basis for believing that replacement blood offered by or on behalf of the beneficiary would endanger the health of a recipient or that the prospective donor's health would be endangered by making a blood donation.  Once a provider accepts a pint of replacement blood from a beneficiary or another individual acting on his/her behalf, the blood is deemed to have been replaced, and, the beneficiary may not be charged for the blood, even though the replacement blood is later found to be unfit and has to be discarded.   When a provider accepts blood donated in advance, in anticipation of need by a specific beneficiary, whether the beneficiary's own blood, that is, an autologous donation, or blood furnished by another individual or blood assurance group, such donations are  considered replacement for pints or units subsequently furnished the beneficiary.    20.6  Part B Premium  (Rev. 12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)
(Medicare General Information, Eligibility, and Entitlement)
20.6  Part B Premium  (Rev. 12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  The Centers for Medicare and Medicaid Services (CMS) updates the Part B premium each year. These adjustments are made according to formulas set by statute. By law, the monthly Part B premium must be sufficient to cover 25 percent of the programs costs, including the costs of maintaining a reserve against unexpected spending increases.  The federal government pays the remaining 75 percent.   Below are the annual Part B premium amounts from Calendar Year (CY) 1996 to 2006. For these years, and years prior to 1996, the Part B premium is a single established rate for all beneficiaries.   Year  Part B Premium  1996  $42.50  1997  $43.80  1998  $43.80  1999  $45.50  2000  $45.50  2001  $50.00  2002  $54.00  2003  $58.70  2004  $66.60  2005  $78.20  2006  $88.50   Beginning on January 1, 2007, the Part B premium is based on the income of the beneficiary. See the following Change Requests (CRs) for more information.
(Medicare General Information, Eligibility, and Entitlement)
For 2008, see CR 5345 at http://www.cms.hhs.gov/transmittals/downloads/R41GI.pdf   For 2008, see CR 5830 at http://www.cms.hhs.gov/transmittals/downloads/R49GI.pdf   For 2009, see CR 6258 at http://www.cms.hhs.gov/transmittals/downloads/R56GI.pdf   For 2010, see CR 6690 found on the 2009 Transmittals page at http://www.cms.hhs.gov/Transmittals/2009Trans/list.asp For 2011, see CR 7224 found on the 2010 Transmittals page at http://www.cms.gov/Transmittals/2010Trans/list.asp For 2012, see CR 7567 found on the 2011 Transmittals page at http://www.cms.gov/Transmittals/2011Trans/list.asp For 2013, see CR 8052 found on the 2012 Transmittals page at http://www.cms.gov/Transmittals/2012Trans/list.asp For 2014, see CR 8527 found on the 2013 Transmittals page at http://www.cms.gov/Transmittals/2013Trans/list.asp For 2015, see CR 8982 found on the 2014 Transmittals page at http://www.cms.gov/Transmittals/2014Trans/list.asp For 2016, see CR 9410 found on the 2015 Transmittals page at http://www.cms.gov/Transmittals/2015Trans/list.asp For 2017, see CR 9902 found on the 2016 Transmittals page at http://www.cms.gov/Transmittals/2016Trans/list.asp For 2018, see CR 10405 found on the 2017 Transmittals page at http://www.cms.gov/Transmittals/2017Trans/list.asp For 2019, see CR 11025 found on the 2018 Transmittals page at
(Medicare General Information, Eligibility, and Entitlement)
the 2017 Transmittals page at http://www.cms.gov/Transmittals/2017Trans/list.asp For 2019, see CR 11025 found on the 2018 Transmittals page at http://www.cms.gov/Transmittals/2018Trans/list.asp For 2020, see CR 11542 found on the 2019 Transmittals page at  http://www.cms.gov/Transmittals/2019Trans/list.asp For 2021, see CR 12024 found on the 2020 Transmittals page at  http://www.cms.gov/Transmittals/2020Trans/list.asp For 2022, see CR 12507 found on the 2021 Transmittals page at  http://www.cms.gov/Transmittals/2021Trans/list.asp For 2023, see CR 12903 found on the 2022 Transmittals page at  http://www.cms.gov/Transmittals/2022Trans/list.asp For 2024, see CR 13365 found on the 2023 Transmittals page at  http://www.cms.gov/Transmittals/2023Trans/list.asp
(Medicare General Information, Eligibility, and Entitlement)
30 - Outpatient Mental Health Treatment Limitation  (Rev. 60, Issued: 10- 30-09, Effective: 01 -01-10, Implementation: 01- 04-10)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  The limitation is called the outpatient mental health treatment limitation (the limitation).  The 62 .5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).    January 1, 2012  December 31, 2012, the limitation percentage is 75%.  (Medicare pays 60% and the patient pays 40%).    January 1, 2013  December 31, 2013, the limitation percentage is 81.25%.  (Medicare pays 65% and the patient pays 35%).    January 1, 2014  onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).   For additional details concerning the outpatient mental health treatment limitation, please see the Medicare Claims Processing Manual, Publication 100- 04, chapter 9, section 60 and chapter 12, section 210.  40 - Limitation on Physical Therapy, Occupational Therapy and Speech -Language Pathology Services  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  Coverage of outpatient physical therapy, occupational therapy, and speech- language pathology services under Part B has been limited in some years.  For descriptions of these limitations see Pub 100 -04, Chapter 5, 10.2.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12307GI
(Medicare General Information, Eligibility, and Entitlement)
10/19/2023  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2024  01/02/2023  13365  R11641GI  10/13/2022  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2023  01/03/2023  12903  R11136GI  11/30/2021  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2022  01/03/2022  12507  R10880GI  08/06/2021  Internet Only Manual Updates to Pub. 100 -01, 100- 02, and 100- 04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF)  11/08/2021  12009  R10469GI  11/20/2020  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2021  01/04/2021  12024
(Medicare General Information, Eligibility, and Entitlement)
11/22/2019  Update to Medicare Deductible, Coinsurance and Premium Rates for 2020  01/06/2020  11542  R119GI  11/02/2018  Update to Medicare Deductible, Coinsurance and Premium Rates for 2019  01/07/2019  11025  R111GI  12/08/2017  Update to Medicare Deductible, Coinsurance and Premium Rates for 2018  01/02/2018  10405  R103GI  12/02/2016  Update to Medicare Deductible, Coinsurance and Premium Rates for 2017  01/03/2017  9902  R96GI  11/25/2015  Update to Medicare Deductible, Coinsurance and Premium Rates for 2016  01/04/2016  9410  R89GI  11/21/2014  Update to Medicare Deductible, Coinsurance and Premium Rates for 2015  01/05/2015  8982  R82GI  11/15/2013  Update to Medicare Deductible, Coinsurance and Premium Rates for 2014  01/06/2014  8527  R81GI  12/07/2012  Update to Medicare Deductible, Coinsurance and Premium Rates for 2013  01/07/2013  8052  R80GI  10/26/2012  Manual Updates to Clarify SNF Claims Processing  04/01/2013  8044  R74GI  12/16/2011  Update to Medicare Deductible, Coinsurance and Premium Rates for 2011  01/03/2012  7567  R72GI  11/18/2011  Update to Medicare Deductible, Coinsurance and Premium Rates for 2011  Rescinded and replaced by Transmittal 74  01/03/2012  7567  R65GI  11/19/2010  Update to Medicare Deductible, Coinsurance and Premium Rates for 2011  01/03/2011  7224  R61GI  11/13/2009  Update to Medicare Deductible, Coinsurance and Premium Rates for 2010  01/04/2010  6690  R60GI  10/30/2009  Outpatient Mental Health Treatment Limitation  01/04/2010  6686  R56GI  11/17/2008  Update to Medicare Deductible, Coinsurance and Premium Rates for 2009  01/05/2009  6258  R55GI  11/07/2008  Update to Medicare Deductible, Coinsurance and Premium Rates for 2009 -  Rescinded and replaced by Transmittal 56  01/05/2009  6258  R49GI
(Medicare General Information, Eligibility, and Entitlement)
01/05/2009  6258  R55GI  11/07/2008  Update to Medicare Deductible, Coinsurance and Premium Rates for 2009 -  Rescinded and replaced by Transmittal 56  01/05/2009  6258  R49GI  12/14/2007  Update to Medicare Deductible, Coinsurance and Premium Rates for 2008  01/07/2008  5830  R41GI  10/27/2006  Update to Medicare Deductible, Coinsurance and Premium Rates for 2007  01/02/2007  5345  R31GI  11/04/2005  Update to Medicare Deductible, Coinsurance and Premium Rates for 2006  01/03/2006  4132  R28GI  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100 -01 09/12/2005  3912  R18GI  03/04/2005  Billing for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2005  3681  R12GI  10/22/2004  New Policy and Refinements on Billing Noncovered Charges to Fiscal Intermediaries (FIs)  04/04/2005  3416  R11GI  10/22/2004  Manual Revision Regarding Waiver of Annual Deductible and Coinsurance for Both ASC Facility, and ASC/Hospital Outpatient Department Physician Services  11/22/2004  3471  R10GI  09/10/2004  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year 2005  01/03/2005  3463  R09GI  09/03/2004  Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year 2005  01/03/2005  3463  R03GI  03/12/2004  New Part B Annual Deductible  01/03/2005  3121  R01GI  09/11/2002  Initial Publication of Manual  NA NA
(Medicare General Information, Eligibility, and Entitlement)
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(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 4 - Physician Certification and Recertification of Services   Table of Contents  (Rev. 12425; Issued:  12-21-23)  Transmittals for Chapter 4