evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
40.9.4 - Initial Enrollment & Reenrollment in Part B -ID (Rev. 11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  There are no enrollment periods associated with Part B -ID. Therefore, eligible individuals can enroll at any time without regard t o Medicare enrollment periods. The earliest date on which they may initially enroll depends on when their Medicare Part A entitlement based on ESRD ends, under the following two scenarios:   1. When an individuals Medicare Part A entitlement based on ESRD ends on or after January 1, 2023, they may enroll in Part B -ID any time after their Medicare Part A on the basis of ESRD entitlement ends.    2. When an individuals Medicare Part A entitlement based on ESRD ends prior to January 1, 2023, they may enroll in Par t B-ID beginning October 1, 2022 and their coverage will start the later of January 2023 or the month after they enroll.  Individuals who had previously enrolled in Part B -ID can reenroll at any time if they meet the eligibility requirements in section 40. 9.1.   NOTE: Late enrollment penalties are not  applicable to Part B -ID enrollment. Additional information is outlined under subsection 40.9.7 (Part B -ID Premiums).   40.9.5 - Procedure for Enrolling in Part B -ID (Rev. 11764; Issued 12- 22-22; Implementation:  01-01-2023; Effective 01- 03-23)  Eligible individuals may enroll by:  1. calling SSA at 1 -877-465-0355 and providing an oral attestation, or  2. completing and filing the Application for Enrollment in Part B -ID. Immunosuppressive Drug Coverage Form CMS -10798 and mailing it to the following address:  SOCIAL SECURITY ADMINISTRATION  OFFICE OF CENTRAL OPERATIONS  PO Box 32914 BALTIMORE, MARYLAND 21298   Note: The Office of Central Operations Office of Disability Operations teleservice center (ODO TSC) will only be handling the telephonic enrollments and PC 7 will process the enrollment for Part B -ID.
(Medicare General Information, Eligibility, and Entitlement)
Note: The Office of Central Operations Office of Disability Operations teleservice center (ODO TSC) will only be handling the telephonic enrollments and PC 7 will process the enrollment for Part B -ID.   40.9.6 - Termination of Part B -ID (Rev. 11646; Issued :10-19-22; Effective:01 -01-23; Implementation:01 -03-23)  1. Individuals enrolled in other health coverage are required to notify SSA and terminate Part B -ID a. When a Part B -ID covered individual notifies SSA that they have enrolled in other coverage, and if not  otherwise specified, Part B -ID terminates effective with the first day of the month following the month SSA receives the notification.    b. If the individual states that their other health insurance begins in the future, the individual may request a termination date up to 6 months in the future.   Example: If an individual enrolls in employer health coverage during an employers open enrollment period in October, for a January 1st effective date, the individual can submit their request for termination of the Part B -ID benefit in October or November, and not lose their Part B-ID benefit prior to the January 1st effective date.   c. When a state ends buy -in for Part B -ID because an individual gained full Medicaid eligibility that includes immunosuppressive drug coverage, the individual must report this new eligibility to SSA and terminate Part B -ID coverage.   If a Part B -ID covered individual fails to notify SSA of their enrollment in other health coverage, including employer and Medicaid, Part B- ID will terminate effective the first day of the month after the month in which SSA discovers the individual has other health coverage.     2. Voluntary termination request  In general, Part B -ID terminates effective with the first day of the month following the month in which we receive the request.   There is an exception to this general rule for individuals who had state payment of their Part B-ID premium under a Medicare Savings Program (as d escribed in section 40.9.9) and who are notified by SSA that their state will no longer pay their Medicare Part B -ID premiums. For these individuals the following entitlement end dates apply:
(Medicare General Information, Eligibility, and Entitlement)
a. If the individual files a voluntary termination request within 30 days after the date of the notice that state payment of premiums will end or has ended, the individual's Part B- ID entitlement ends on the last day of the last month for which the state paid the premium.   b. If the individual files the voluntary terminatio n request more than 30 days but not more than 6 months after state payment of Medicare Part B -ID premiums ends, Part B-ID entitlement ends on the last day of the month in which the request is filed.  c. If the individual files the voluntary termination reques t later than the 6th month after state payment of Medicare Part B- ID premiums ends, entitlement ends at the end of the month after the month in which request is filed.   We note that individuals who lose eligibility for state payment of Medicare Part B -ID premiums through a Medicare Savings Program will continue to be eligible for the Part B-ID benefit without interruption with the individual assuming responsibility for paying the Part B -ID premiums, unless they voluntarily terminate. The options for financi al relief from Part B billing in SSAs Program Operations Manual System (POMS), section HI.00815.042, also apply for the Part B -ID coverage here.   3. Death  - Entitlement to Part B -ID continues into the month of death, up to and including the date of death.   4. Non-payment of  premiums   Part B -ID coverage will terminate for non -payment of premiums following the same rules, including grace periods, used for Medicare Part B for monthly billing in sections 40.5 and 40.7.4 of this manual. Note that section 40.5 provides end of coverage information, and section 40.7.4 provides grace period payment information.     5. Individual becomes entitled to Medicare on another basis   In cases where a Part B -ID enrollee becomes eligible for Medicare based on age, disability, or ESRD , Part B -ID will terminate effective with the last day of the month prior to the month in which they become entitled on the other basis.  Equitable relief for retroactivity may apply.   40.9.7 - Part B -ID Premiums (Rev.  11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)
(Medicare General Information, Eligibility, and Entitlement)
40.9.7 - Part B -ID Premiums (Rev.  11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  Part B -ID premiums may be adjusted based on rounding, the income -related monthly adjusted amounts (IRMAA), and the hold harmless provision, but will not be increased based on late enrollment.   If the indivi dual is directly billed for premiums, billing will be on a monthly basis.  40.9.8 - Procedure for Termination of Part B -ID (Rev. 11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  Individuals enrolled in the Part B -ID benefit can repo rt other coverage and request to terminate their enrollment by either: 1. calling SSA at 1 -877-465-0355 to disenroll over the phone to verbally request termination, or  2. completing and submitting Form CMS -1763, Request for Termination of Premium Hospital and/o r Supplementary Medical Insurance, and mailing it to:   SOCIAL SECURITY ADMINISTRATION  OFFICE OF CENTRAL OPERATIONS  PO Box 32914 BALTIMORE, MARYLAND 21298   3. any other request to SSA that shows the unequivocal desire to end coverage.   Note: The Office of Central Operations Office of Disability Operations teleservice center (ODO TSC) only will handle the telephonic disenrollment and PC 7 will process the disenr ollment for Part B -ID.  When the individual is reporting other coverage and choosing a future termination date, a termination effective date that is more than 6 months in the future cannot  be processed   40.9.9 - Medicare Savings Programs for Part B -ID Premiums  (Rev. 11764; Issued 12- 22-22; Implementation: 01- 01-2023; Effective 01- 03-23)  Individuals enrolled in Part B -ID with limited income and resources may be eligible for assistance through the Medicare Savings Programs (MSPs). The MSPs include three eligibility groups that cover Part B -ID premiums and sometimes cost sharing, including:    Qualified Medicare Beneficiary (QMB)   Specified Low -Income Medicare Beneficiary (SLMB)   Qualifying Individuals (QI)
(Medicare General Information, Eligibility, and Entitlement)
 Qualified Medicare Beneficiary (QMB)   Specified Low -Income Medicare Beneficiary (SLMB)   Qualifying Individuals (QI)   There are two ways to enroll in the MSPs for the payment of the Part B -ID premiums.  First, once enrolled in Part B -ID, individuals may apply for the MSPs and be determined eligible by their state for an MSP eligibility group based on Part B -ID.   Second, individuals who are enrolled in an MSP group and los e Medicare entitlement based on ESRD 36 months after the month in which they receive a kidney transplant can transition to an MSP based on Part B -ID enrollment without a break in coverage if: (1)they attest that they do not have other health coverage as de scribed in 40.9.1 by the end of the 36th month after the month in which they receive a kidney transplant; and (2) the state redetermines the individuals Medicaid eligibility on all bases and does not otherwise find the individual ineligible for the MSP gr oup.  50 - Identifying the Patient's Health Insurance Record Using the  Medicare Card  (Rev. 124, Issued: 05- 17-19, Effective: 06 -18-19, Implementation: 06- 18-19  As part of health insurance electronic data processing, Medicare cards are issued by CMS to individuals who have established entitlement to health insurance.   Below is an example of the Medicare card.   New Medicare Card           New Medicare Card  Front             New Medicare Card Back                                 The Medicare card is used to identify the individual as being entitled and also serves as a source of info rmation required to process Medicare claims or bills. It displays the beneficiary's name, Medicare number, and effective date of entitlement to hospital insurance and/or medical insurance. The Social Security Administration's Social Security Office assists  in replacing a lost or destroyed Medicare cards.   50.1 - Medicare Beneficiary Identifier (M BI) (Rev.  12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23)
(Medicare General Information, Eligibility, and Entitlement)
50.1 - Medicare Beneficiary Identifier (M BI) (Rev.  12046, Issued:05- 18-23, Effective:01-01-23, Implementation:06-21-23)  The term Medicare beneficiary identifier (M BI) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card tran sition period and after for certain business areas that will continue to use the HICN as part of their processes.   60 - Medicare Part C, Medicare+Choice  (Rev. 1, 09-11-02)  Medicare Part C, which is also known as Medicare+Choice, is a Medicare program that  gives beneficiaries more choices among health plans.  Everyone who has Medicare Parts A and B is eligible, except those who have end stage renal disease, and were not in a Medicare+Choice plan at the onset of this condition.  Public Law 105-33, the Balanced Budget Act of 1997, establishes a new authority permitting contracts between CMS and a variety of different managed care and fee -for-service entities.  The types of entities that may be granted contracts under this new authority include:   Coordinated care plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Provider-Sponsored Organizations
(Medicare General Information, Eligibility, and Entitlement)
You may be asked to show this card when you get health care services. Only give your personal Medicare information to health care providers, your insurers, or people you trust who work with Medicare on your behalf. WARNING: Intentionally misusing this card  may be considered fraud and/or other violation of federal law and is punishable by law. Es posible que le pidan que muestre esta tarjeta cuando reciba servicios de cuidado mdico. Solamente d su informacin personal de Medicare a los proveedores de salud, sus aseguradores o personas de su confianza que trabajan con Medicare en su nombre.  ADVERTENCIA! El mal uso intencional de esta tarjeta puede ser considerado como fraude y/u otra violacin de la ley federal y es sancionada por la ley.  1-800- MEDICARE (1-800-633- 4227 /  TTY: 1 -877-486-2048); Medicare.gov  (PSOs).  A PSO is defined as a public or private entity established by health care providers, which provide a substantial proportion of health care items and services directly through affiliated providers who share, directly or indirectly, substantial financial risk.    Religious fraternal benefit society plans which may restrict enrollment to members of the church, convention or group with which the society is affiliated.  Payments to such plans may be adjusted, as appropriate to take into account the actuarial characteristics and experience of plan enrollees.    Private fee -for-service plans which reimburse providers on a f ee-for-service basis, and are authorized to charge enrolled beneficiaries up to 115 percent of the plan's payment schedule (which may be different from the Medicare fee schedule).
(Medicare General Information, Eligibility, and Entitlement)
In addition to the Medicare+Choice contractors, beginning in January, 1999, up to 390,000 beneficiaries will have the choice (on a demonstration basis ending January 1, 2003) of enrolling in a Medical Savings Account (MSA) option.  Under this option, beneficiaries would obtain high deductible health policies that pay for at least  all Medicare- covered items and services after an enrollee meets the annual deductible of up to $6,000.  The difference between the premiums for such high deductible policies and the applicable Medicare+Choice premium amount would be placed into an account  for the beneficiary to use in meeting his or her deductible expenses.   Past 1876 Contracts  - HMO/CMP risk plans that remain in compliance with current contracting standards and comply with new requirements established under this statutory authority automa tically transitioned into the Part C Medicare+Choice program.  Section 1876 risk- based contractors were paid under a new Medicare+Choice payment methodology rather than the prior method in section 1876(a), and were subject to certain other Medicare+Choice provisions.  The Secretary no longer accepts new 1876 risk applications.  As of January 1, 1999, existing 1876 risk- based contracts were terminated, and plans in good standing transitioned to the Medicare+Choice program.   Repeal of Cost Option -  As of August 5, 1997, the Secretary is prohibited from entering into any new 1876 cost -based contracts, unless the plan is a Health Care Prepayment Plan with an agreement under section 1833 of the Social Security Act.  The 1876 cost -based payment authority is repeal ed and all cost contracts are terminated as of December 31, 2002.  Limited HCPP Option  - Beginning January 1, 1999, the Secretary may only contract with those HCPPs that are sponsored by Union or Employer groups, or HCPPs that do not "provide, or arrange f or the provision of, any inpatient hospital services ...."  This amendment will result in the termination of section 1833 agreements with any organization that does not meet the new definition.  CMS will establish transition rules for 1876 risk- based contr actors that currently receive reimbursement on a cost basis for enrollees remaining under a previous HCPP agreement.  For more information, see the Managed Care Manual.  Transmittals Issued for this Chapter
(Medicare General Information, Eligibility, and Entitlement)
Rev #  Issue Date  Subject  Impl Date  CR#  R12046GI  05/18/2023  Update to the Internet Only Manual (IOM) Publication (Pub.) 100-01, IOM Chapter 2 Hospital Insurance and Supplementary Medical Insurance  06/21/2023  13189  R11764BP  12/22/20 22 New Medicare Part B Immunosuppressant Drug Benefit (PBID) - Implementation  01/03/2023  12804  R11646GI  10/19/2022  New Medicare Part B Immunosuppressant Drug Benefit (PBID)  Implementation  Rescinded and Replaced by Transmittal 11764   01/03/2023  12804   07/28/2022  New Medicare Part B Immunosuppressant Drug Benefit (PBID)  Implementation  SENSITIVE/CONTOVERSIAL DO NOT POST - Rescinded and Replaced by Transmittal 11646  01/03/2023  12804  R124GI  05/17/2019  Update to Publication (Pub.) 100 -01 to Provide Language-Only Changes for the New Medicare Card Project   06/18/2019  11240  R01MGI  09/11/2002  Initial Publication of Manual  NA NA  Back to top of Chapter
(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations   Table of Contents  (Rev. 12307, Issued:  10-19-23)  Transmittals for Chapter 3   10 - Hospital Insurance (Part A)  10.1 -  Inpatient Hospital Deductible  10.2 -  Coinsurance  10.2.1 -  Inpatient Services  10.2.2 -  Durable Medical Equipment (DME) Furnished as a Home Health Benefit  10.3 -  Basis for Determining the Part A Coinsurance Amounts  10.4 -  Benefit Period (Spell of Illness)  10.4.1 -  Starting a Benefit Period  10.4.2 -  Ending a Benefit Period 10.4.3 -  Definition of Hospital or SNF for Ending a Benefit Period  10.4.3.1 -  Hospital Stay and End of Benefit Period  10.4.3.2 -  SNF Stay and End of Benefit Period  10.4.4 -  Definition of Inpatient for Ending a Benefit Period 20 - Supplementary Medical Insurance (SMI) (Part B)  20.1 -  Supplementary Medical Insurance Incurred Expenses  20.2 -  Part B Annual Deductible  20.3 -  Part B Coinsurance  20.4 -  Exceptions to Annual Deductible and Coinsurance  20.4.1 -  Applications of Deductible and Coinsurance in Liability and Indemnification Situations  20.5 -  Blood Deductibles (Part A and Part B)  20.5.1 -  Part A Blood Deductible  20.5.2 -  Part B Blood Deductible  20.5.3 -  Items Subject to Blood Deductibles  20.5.4 -  Obligations of the Beneficiary to Pay for or Replace Deductible Blood 20.5.4.1 -  Replacement of Blood  20.6 -  Part B Premium 30 - Outpatient Mental Health Treatment Limitation  40 - Limitation on Physical Therapy, Occupational Therapy and Speech -Language Pathology Services  10 - Hospital Insurance (Part A)   10.1 - Inpatient Hospital Deductible  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
10.1 - Inpatient Hospital Deductible  (Rev. 1, 09- 11-02)  The patient is responsible for a deductible amount for inpatient hospital services in each benefit period.  For each year after 1991, the Secretary of the Department of Health and Human Services (DHHS) is required to set the deductible and coinsurance amounts between September 1 and September 15 of the preceding year.  The deductible will be set at an amount equal to the deductible for the preceding year, changed by the same percentage as applies to PPS payment rates, and adjusted to reflect changes in real  case mix.  The deductible and coinsurance amounts are shown in the chart in 10.3 of this chapter.   The coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur.  The deductible is satisfied only by charges for covered Part A services.  Expenses for covered services count toward the deductible on an incurred, rather than paid, basis.  Expenses incurred in one benefit period cannot be applied toward the deductible in a later benefit period.  Expenses incurred in meeting the blood deductible do not count toward the inpatient hospital deductible.  A reduction in benefit days resulting from confinement in a psychiatric hospital, on and immediately preceding the date of entitlement, does not affect the amount of the deductible for which the patient is responsible.   If the actual charge is less than the deductible and the customary charge, the customary charge is applied to the deductible.   A beneficiary is not responsible for payment of the deductible for an inpatient stay if the provider has been determined to be liable because the care was not medically necessary or because the care provided was custodial.  10.2 - Coinsurance  (Rev. 1, 09- 11-02)  The following subsections describe coinsurance.   10.2.1 - Inpatient Services  (Rev. 1, 09- 11-02)  In each benefit period, the patient is responsible for coinsurance amounts equal to:    One-fourth of the inpatient hospital deductible for each day of inpatient hospital services from the 61st through the 90th days;
(Medicare General Information, Eligibility, and Entitlement)
In each benefit period, the patient is responsible for coinsurance amounts equal to:    One-fourth of the inpatient hospital deductible for each day of inpatient hospital services from the 61st through the 90th days;    One-half of the inpatient hospital deductible for each lifetime reserve day (the 91st through the 150th days of inpatient hospital services); and    One-eighth of the inpatient hospital deductible for each day of extended care services from the 21st through the 100th days.  A beneficiary is not responsible for payment of the coinsurance for a stay if the provider has been determined to be liable becaus e the care was not medically necessary or because the care provided was custodial.   Use the chart in 10.3 of this chapter to determine the applicable coinsurance amounts.  Where the actual charge to the patient for the 61st through the 90th days of inpatient hospital services is less than the applicable coinsurance amount, the coinsurance is the actual charge per day.  Where the actual charge to the patient for lifetime rese rve days is less than the coinsurance amount for those days, the beneficiary may be deemed to have elected not to use the days because he/she would not benefit from their utilization.   10.2.2 - Durable Medical Equipment (DME) Furnished as a Home Health Benefit  (Rev. 1, 09- 11-02)  The patient is responsible for 20 percent of the payment amount for DME furnished as a home health benefit.   10.3 - Basis for Determining the Part A Coinsurance Amounts  (Rev.12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  The applicable inpatient deductible is the one in effect during the calendar year in which the patient's benefit period begins (i.e., in most cases, the year in which the first inpatient hospital services are furnished in the benefit period). Except for 1989, the coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur.   When Deductible and/or Coinsurance Are Applicable for Part A