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(Medicare Benefit Policy Manual)
Transmitt als Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R255BP  01/25/2019 Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018 02/26/2019  11120  R165BP  12/21/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 01/07/2013  8005 R163BP  11/30/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012  Rescinded and replaced by Transmittal 165  01/07/2013  8005 R158BP  08/24/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle  Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012  Rescinded and replaced by Transmittal 163  01/07/2013  8005 R111BP  09/25/2009 Comprehensive O utpatient Rehabilitation Facility (CORF) Services  10/26/2009  6005 R21BP  09/24/2004 Medicare Comprehensive Outpatient Rehabilitation Facility Coverage  10/25/2004  3315 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 16 - General Exclusions From Coverage   Table of Contents (Rev. 1 98, 11-06-14)  Transmittals for Chapter 16   10 - General Exclusions from Coverage  20 - Services Not Reasonable and Necessary  30 - Foot Care  40 - No Legal Obligation to Pay for or Provide Services  40.1 - Indigence  40.2  Provider, Physician, or Supplier Bills Only Insured Patients  40.3 - Medicare Patient Has Other Health Coverage  40.4 - Items Covered Under Warranty  40.5 - Members of Religious Orders  40.6 - Am bulance Services  50 - Items and Services Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments  50.1 - Items and Services Which a Non -Federal Provider Furnishes Pursuant to an Authorization Issued by a Federal Agency  50.1.1 - Veterans Administration (VA) Authorized Services  50.1.2 - Medicare Secondary Payment Where VA Authorizes Fewer Day s Than Total Number of Covered Days in the Stay  50.1.3 - Effect of VA Payments on Medicare Deductible and Utilization  50.1.4 - VA Fee Basis Card"  50.1.5 - Services Authorized by Indian Health Service  50.2 - Items and Services Furnished by Federal Provider of Services or Federal Agency  50.3 - Items or Services Paid for by Governmental Entity  50.3.1 - Application of Exclusion to State and Local Government Providers  50.3.2 - Application of Exclusion to Nongovernmental Providers, Physicians and Suppliers  50.3.3 - Examples of Application of Government Entity Exclusion  50.4 -  TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration)  50.5 -  Active Duty Members of Uniform ed Services  60 - Services Not Provided Within United States  70 - Services Resulting from War  80 - Personal Comfort Items  90 - Routine Services and Appliances  100 -  Hearing Aids and Auditory  Implants  110 -  Custodial Care  110.1 -  Custodial Care Under a Hospice Program  120 -  Cosmetic Surgery  130 -  Charges Imposed by Immediate Relatives of the Patient or Members of the Patients Household 140 -  Dental Services Exclusion  150 -  Services Reimbursable Under Automobile, No Fault,  Any Liability Insurance or Workers Compensation 170 -  Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider  180 -  Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
(Medicare Benefit Policy Manual)
10 - General Exclusions f rom Coverage  (Rev.  198, Issued: 11- 06-14, Effective: 01- 01-15, Implementation: 01- 05-15)  No payment can be made under either the hospital insurance or supplementary medical insurance program for certain items and services, when the following conditions exist:    Not reasonable and necessary (20);    No legal obligation to pay for or provide (40);    Paid for by a governmental entity (50);    Not provided within United States (60 );    Resulting from war (70);    Personal comfort (80);    Routine services and appliances (90 );    Custodial care (110 );    Cosmetic surgery (120);    Charges by immediate relatives or members of household (130 );    Dental services ( 140);    Paid or expected to be paid under workers compensation ( 150);    Non-physician services provided to a hospital inpatient that were not provided directly or arranged for by the hospital (170);    Services Related to and Required as a Result of Services Which are not Covered Under Medicare ( 180);    Excluded foot care services and supportive devices for feet (30); or ,    Excluded investigational devices (See Chapter 14).   20 - Services Not Reasonable and Necessary  (Rev. 1, 10- 01-03) A3-3151, HO -260.1, B3- 2303, AB -00-52 - 6/00   Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a  malformed body member are not covered, e.g., payment cannot be made for the rental of a special hospital bed to be used by the patient in their home unless it was a reasonable and necessary part of the patients treatment.  See also 80 .  A health care item or service for the purpose of causing, or assisting to cause, the death of any individual (assisted suicide) is not covered.  This prohibition does not apply to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing death.   30 - Foot Care  (Rev. 1, 10- 01-03)
(Medicare Benefit Policy Manual)
30 - Foot Care  (Rev. 1, 10- 01-03)  Some foot care is excluded and some is covered. A description of both is in Chapter 15, 290.  40 - No Legal Obligation to Pay for or Provide Services (Rev. 1, 10- 01-03) A3-3152, HO -260.2, B3- 2306  Program payment may not be made for items or services which neither the beneficiary nor any other person or organization has a legal obligation to pay for or provide.  This exclusion applies where items and services are furnished gratuitously without regard to the beneficiarys ability to pay and without expectation of payment from any source, such as free x -rays or immunizations provided by health organizations.  However, Medicare reimbursement is not precluded merely because a provider, physician, or supplier waives the charge in the case of a particular patient or group or class of patients, as the waiver of charges for some patients does not impair the right to charge others, including Medicare patients.  The determinative factor in applying this exclusion is the reason the particular individual is not charged.   The following sections illustrate the applicability of this exclusion to various situations involving services other than those paid for directly or indirectly by a governmental entity.  (For a discussion of the latter, see 50.)  40.1 - Indigence  (Rev. 1, 10- 01-03) A3-3152.A, H O-260.2.A   This exclusion does not apply where items and services are furnished to an indigent individual without charge because of their inability to pay, if the provider, physician, or supplier bills other patients to the extent that they are able to pay .  40.2 - Provider, Physician, or Supplier Bills Only Insured Patients  (Rev. 1, 10- 01-03) A3-3152.B, HO -260.2.B
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40.2 - Provider, Physician, or Supplier Bills Only Insured Patients  (Rev. 1, 10- 01-03) A3-3152.B, HO -260.2.B   Some providers, physicians, and suppliers waive their charges for individuals of limited means, but they also expect to be paid where the patie nt has insurance which covers the items or services they furnish.  In such a situation, because it is clear that a patient would be charged if insured, a legal obligation to pay exists and benefits are payable for services rendered to patients with medical  insurance if the provider, physician, or supplier customarily bills all insured patients -  not just Medicare patients -  even though non-insured patients are not charged.   Individuals with conditions which are the subject of a research project may receive treatment financed by a private research foundation.  The foundation may establish its own clinic to study certain diseases or it may make grants to various other organizations.  In most cases, the patient is not expected to pay for treatment out -of-pocket , but if the patient has insurance, the parties expect that the insurer will pay for the services.  In this situation, a legal obligation is considered to exist in the case of a Medicare patient even though other patients may not have insurance and are not  charged.   40.3 - Medicare Patient Has Other Health Coverage  (Rev. 1, 10- 01-03) A3-3152.C, HO -260.2.C   Payment is not precluded under Medicare if the patient is covered by another health insurance plan or program, which is obligated to provide or pay for the same services.   However, Medicare does not pay until after the other payer has paid in the following situations:   Services covered by automobile medical or no -fault insurance;    Services rendered during a specified period of up to 30 months to individua ls eligible or entitled solely on the basis of end stage renal disease (ESRD) who are insured under an employer group health plan;    Services rendered to individuals age 65 or over and spouses age 65 or over who are insured under an employer group health pl an by virtue of current employment status;    Services rendered to individuals under age 65 entitled to Medicare based on disability and have large group health plan coverage based on the individuals current employment status or the current employment statu s of a family member; and    Services covered by workers compensation.
(Medicare Benefit Policy Manual)
 Services covered by workers compensation.   In these cases, the other plan pays primary benefits and if the other plan does not pay the entire bill, secondary Medicare benefits may be payable.  Medicare is also secondary to the extent that a liability insurer has paid for services.   See the Medicare Secondary Payment (MSP) Manual, Pub. 100- 05.  40.4 - Items Covered Under Warranty  (Rev. 1, 10- 01-03) A3-3152.D, HO -260.2.D   When defective equipment or a defective medical device is replaced under a warranty, hospital or other provider services rendered by parties other than the warrantor are covered despite the warrantors liability.  However, see the Medicare MSP Manual (CMS Pub. 100- 05) for requirements for recovery under the liabi lity insurance provisions.   With respect to payment for the device itself under cost reimbursement, the following rules apply:    If equipment or a device is replaced free of charge by the warrantor, no program payment may be made, since there was no charge involved.   If replacement equipment or device from another manufacturer had to be substituted because the replacement offered under the warranty was not acceptable to the beneficiary or the beneficiarys physician, payment may be made for the replaced devi ce.   If the warrantor supplied the replaced equipment or device, but some charge or a pro rata payment was imposed, program payment may be made for the partial payment imposed for the device furnished by the warrantor.    If an acceptable replacement could h ave been obtained free of charge under a warranty but the provider chose to purchase one instead, payment cannot be made for the purchased device under the prudent buyer rules.  (See Provider Reimbursement Manual, Part 1, 2103.)    If an acceptable replacem ent could have been purchased at a reduced price under a warranty but the full price was paid to the original manufacturer or a new replacement was purchased from a different manufacturer or other source, coverage is limited to the amount that would have been paid under the warranty.   While payments to a hospital for inpatient services under the prospective payment system (PPS) are not reduced to reflect collections under warranty provisions for medical devices, cost -based reimbursed hospitals and exempt units are subject to the prudent buyer rules.
(Medicare Benefit Policy Manual)
40.5 - Members of Religious Orders  (Rev. 1, 10- 01-03) A3-3152.E, HO -260.2.E   A legal obligation to pay exists where a religious order either pays for or furnishes services to members of the order.  Although medi cal services furnished in such a setting would not ordinarily be expressed in terms of a legal obligation, the order has an obligation to care for its members who have rendered life -long services, similar to that existing under an employers prepayment pla n.  Thus, payment may be made for such services whether they are furnished by the order itself or by independent sources that customarily charge for their services.   40.6 - Ambulance Services  (Rev. 1, 10- 01-03) B3-2306  There are numerous methods of financing ambulance companies.  For example, some volunteer organizations do not charge the patient or any other person but ask the recipient of services for a donation to help offset the cost of the service.  Although the recipients may be under considera ble moral and social pressure to donate, they are not required to do so, and there is no enforceable legal obligation on the part of the individual or anyone else to pay for the services. Thus, Medicare benefits would not be payable.  However, services of volunteer ambulance corps are not categorically excluded.  Many such companies regularly charge for their services and Medicare covers these services.   Some ambulance companies provide services without charge to residents of specific geographical areas but  charge non -residents to the extent they are able to pay (e.g., through private health insurance).  Under those circumstances, the free services provided the residents would be excluded from coverage, while the services furnished non-residents would be cov ered.
(Medicare Benefit Policy Manual)
Ambulance companies which charge membership fees generally do not charge additional fees for services covered under the membership plan, although they may charge for certain other services (e.g., additional trips or mileage).  Services furnished by such ambulance companies including services for which prepayment is made under the membership plan, are considered to be services for which there is a legal obligation to pay.  Therefore, such services are reimbursable provided the ambulance company bills all third party payers.  Membership fees and insurance premiums are not incurred expenses under Medicare (see the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 10) and are not reimbursable.   50 - Items and Servic es Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments  (Rev. 1, 10- 01-03) A3-3153, HO -260.3, B3- 2309  The law contains three separate exclusions applicable to items and services furnished, paid for or authorize d by governmental entities.  In general, payment may not be made for items and services:    Furnished by a provider (Governmental or non governmental) or other person at public expense pursuant to an authorization issued by a Federal agency ( 50.1 );   Furnished by a provider of services or agency of the Federal government ( 50.2 ); and   Paid for directly or indirectly by a Federal, State, or local governmental entity (50.3).  The A/B MAC (A) or (B)  applies each of these exclusions separately, i.e., benefits are excluded where any one of the exclusions applies.  50.1 - Items and Services Which a Non -Federal Provider Furnishes Pursuant to an Authorization Issued by a Federal Agency (Rev. 1, 10- 01-03) A3-3153.1, HO -260.3.B, B3- 2309.2   50.1.1 - Veterans Administration (VA) Authorized Services  (Rev. 1, 10- 01-03) A3-3153.1.A, B3 -2309.2, A3- 3153.1.E, HO -260.3.B
(Medicare Benefit Policy Manual)
Generally, an authorization issued by the Veterans Administration (VA) binds the VA to pay in full for the items and services provided.  No payment is made under Medicare for such authorized services.  NOTE:  Medicare can reimburse veterans for (or credit toward Medicare deductible or coinsurance amounts) VA copayment amounts charged for VA authorized services furnished by non- VA sources.   Medicare does not pay for any item or service rendered by a non -Federal provider pursuant to an authorization issued by a Federal agency, under the terms of which the Federal government agrees to pay for the services.   The VA may authorize non- Federal providers or private physicians or other suppliers to render services at Federal expense.  For example, the VA may pay for treatment of veterans in non- VA hospitals for servi ce connected disabilities and, in certain circumstances, for nonservice -connected disabilities, provided the VA has given prior authorization for the services.  The VA may also agree to pay for emergency services furnished a veteran who appears at a hospit al without prior authorization, provided a notification of the veterans admission and a request for authorization to provide care at VA expense is submitted to the VA within 72 hours after the admission.  As a general rule, the VA does not authorize inpat ient services at non -VA facilities for treatment of nonservice -connected conditions.  Accordingly, the A/B MAC (A) should receive few, if any, requests for reimbursement for a VA copayment for treatment in a non-VA provider.  If a beneficiary requests reim bursement for the amount of the VA copayment, the beneficiary must submit to the A/B MAC (A) , along with their request, VA Form 10 -9014, Statement of Charges for Medical Care.  These requests will be handled on an ad hoc basis. For further guidance contact :  Centers for Medicare & Medicaid Services  Center for Medicare Management  Provider Billing Group 7500 Security Boulevard  Baltimore, Maryland 21244- 1850
(Medicare Benefit Policy Manual)
Centers for Medicare & Medicaid Services  Center for Medicare Management  Provider Billing Group 7500 Security Boulevard  Baltimore, Maryland 21244- 1850  The VA may authorize up to six months of care in non- VA SNFs for veterans requiring such care after t ransfer from a VA hospital.  Services furnished pursuant to a VA authorization do not count against the 100 days of extended care benefits available in a benefit period.  Where a veteran remains in a SNF until VA benefits are exhausted, extended care benef its could begin under Medicare.  Such benefits begin with the first day after the VA benefits are exhausted, provided a physician certifies that the individual still requires skilled nursing care on a continuing basis for a condition for which the patient received inpatient hospital services or which arose while the patient was still being treated in the facility for such a condition.  The 3- day qualifying hospital stay and 30-day transfer requirements of the law must be met as of the time of entrance to th e facility.   Where an authorization from the VA was not given to the party rendering the services, Medicare payment is not precluded even though the individual might have been entitled to have payment made by the VA had they requested the authorization.  A lso, Medicare secondary benefits may be payable where the VA authorizes fewer days than the total number of covered days in the stay.   Generally it is advantageous for Medicare beneficiaries who are veterans to have items and services paid for by the VA where possible, since in most cases the VA has no deductible or coinsurance requirements.  Also, services paid for in full by the VA do not count against the individuals maximum number of benefit days or visits available in a Medicare benefit period.
(Medicare Benefit Policy Manual)
However, the VA may charge veterans copayments for treatment of nonservice -connected conditions (during periods of 90 days duration within a period of 365 days) if a veterans income exceeds a specified amount ( 38 CFR Part 17).  The VA may charge the beneficiary a copayment for physician/supplier and outpatient services.  The amount of the copayment is equal to 20 percent of the estimated average cost (during the calendar year in which the services are furnis hed) of an outpatient visit in a VA facility.  The VA determines the estimated average cost. The beneficiary pays the copayment amount directly  to the VA, i.e., the VA does not reduce its payments to physicians/suppliers or for outpatient services.  The total amount of a veterans copayment obligation for all services received (inpatient and outpatient, authorized or furnished directly by the VA) during any 90- day period within the 365- day period cannot exceed the amount of the inpatient Medicare deductible  in effect on the first day of the 365- day period.  Medicare pays secondary benefits to the beneficiary for VA copayment amounts in accordance with 50.1.4 .  The charges for the following services are credited to the Medicare deductibles, on the basis of Medicare fee schedule or allowable amounts, even though the Federal Agency (VA) has not yet paid for them.   Charges for services that exceed the VA copayment;    Services rendered in a non -VA facility that are not authorized b y the VA; or    Services rendered after VA benefits are exhausted in a non -VA facility.   Crediting of VA payments to Medicare deductibles is handled in the same manner as the crediting of employer group health plan payments.  See Pub 100- 05, the Medicare Secondary Payer (MSP) Manual, Chapter 3, for billing and Chapter 5 for payment instructions.  Medicare can pay for such services where neither the physician/supplier nor beneficiary has claimed benefits from the VA.
(Medicare Benefit Policy Manual)
Medicare may also pay for (covered) servic es for which the VA does not make any payment.  For example, if a veteran is authorized fee basis care at VA expense for a service connected back injury, and receives treatment for a different condition for which the VA does not pay, Medicare can pay for  the (covered) services that are not reimbursable by the VA.   50.1.2 - Medicare Secondary Payment Where VA Authorizes Fewer Days Than Total Number of Covered Days in the Stay  (Rev. 1, 10- 01-03) A3-3153.1.C, HO -260.3.B   The Medicare secondary payment is the  lower of:    The gross amount payable by Medicare for all covered days in the stay (without regard to deductible or coinsurance) minus the amount paid by the VA for Medicare covered services, or    The gross amount payable by Medicare (without regard to deductible or coinsurance) minus any applicable Medicare deductible or coinsurance.   EXAMPLE:   The VA authorizes payment for 4 days of a 7- day stay.  Charges for the 4 days total $2,350.  The VA reimburses the hospital that amount.  The gross amount payabl e by Medicare (unreduced by deductible and coinsurance) for the 7 -day stay is $3,350.  The beneficiarys Part A deductible has not been met.  The Medicare secondary payment is determined by subtracting the VA payment from the gross amount payable by Medicare:  $3,350 -  $2,350 = $1,000.  Medicare pays $1,000, which is less than the gross amount payable by Medicare minus the Medicare deductible ($3,350 -  $812 = $2,538).  The beneficiarys Part A deductible is met by the VA payment.   50.1.3 - Effect of VA Paym ents on Medicare Deductible and Utilization  (Rev. 1, 10- 01-03) A3-3153.1.D, HO -260.3.B