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INTRODUCTION

Part B of Medicare is intended to fill some of the gaps in medical insurance coverage left under Part A. After the beneficiary meets the annual deductible, Part B will pay 80% of the "reasonable charge" for covered services, the reimbursement rate determined by Medicare; the beneficiary is responsible for the remaining 20% as "co-insurance." Unfortunately, the "reasonable charge" is often less than the provider's actual charge. If the provider agrees to "accept assignment," he agrees to accept Medicare's "reasonable charge" rate as payment in full and the patient is only responsible for the remaining 20%. If the provider does not accept assignment, the patient will be responsible for paying a portion of the difference between Medicare's reimbursement rate (the reasonable charge) and the provider's actual charge.

Since 1972, individuals receiving Social Security retirement benefits, individuals receiving Social Security disability benefits for 24 months, and individuals otherwise entitled to Medicare Part A, are automatically enrolled in Part B unless they decline coverage. Others must enroll in Part B by filing a request at the Social Security office during certain designated periods.

The major benefit under Part B is payment for physicians' services. In addition, home health care, durable medical equipment, outpatient physical therapy, x-ray and diagnostic tests are also covered. Since January 1, 1998 home care is covered under Part B if the individual does not meet the Part A prior institutional requirements, received coverage under Part A for the maximum annual 100 visits, or only has Part B.

The following is a list of items and services which can be covered under Part B:

  1. Physicians' services;
  2. Home Health Care;
  3. Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians' services;
  4. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;
  5. X-ray therapy, radium therapy and radioactive isotope therapy;
  6. Surgical dressings, and splints, casts and other devices used for fractures and dislocations;
  7. Durable medical equipment;
  8. Prosthetic devices;
  9. Braces, trusses, artificial limbs and eyes;
  10. Ambulance services;
  11. Some outpatient and ambulatory surgical services;
  12. Some outpatient hospital services;
  13. Some physical therapy services;
  14. Some occupational therapy;
  15. Some outpatient speech therapy;
  16. Comprehensive outpatient rehabilitation facility services;
  17. Rural health clinic services;
  18. Institutional and home dialysis services, supplies and equipment;
  19. Ambulatory surgical center services;
  20. Antigens and blood clotting factors;
  21. Qualified pyschologist services;
  22. Therapeutic shoes for patients with severe diabetic foot disease;
  23. Influenza, Pneumococcal, and Hepatitis B vaccine;
  24. Some mammography screening;
  25. Some pap smear screening, breast exams, and pelvic exams;
  26. Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.

Medicare Part B is fairly comprehensive but far from complete. There are certain items and services which are excluded from coverage. Excluded services include:

  1. Services which are not reasonable or necessary;
  2. Custodial care;
  3. Personal comfort items and services;
  4. Care which does not meaningfully contribute to the treatment of illness, injury, or a malformed body member;
  5. Prescription drugs which do not require administration by a physician;
  6. Routine physical checkups;
  7. Eyeglasses or contact lenses in most cases
  8. Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses;
  9. Hearing aids and examinations for hearing aids;
  10. Immunizations except for influenza, pneumococcal and hepatitis B vaccine;
  11. Cosmetic surgery;
  12. Most dental services
  13. Routine foot care.

Part B Premium, Deductible and Co-pays

Medicare's Part B is optional and is financed largely by monthly premiums paid by individuals enrolled in the program. Participants may have this premium automatically deducted from their Social Security check. Since 2007, for the first time in the history of the Medicare program, the premium has been income based.

Click this link for this year's Part B premium breakdown by income.

Part B has an annual deductible requirement, as well. Each year, before Medicare pays anything, the patient must incur medical expenses equal to the deductible, based on Medicare's approved "reasonable charge," not on the provider's actual charge.

As described above, a major problem with Medicare Part B is the difference between the cost of medical items or services, particularly physicians' services, and the Medicare approved "reasonable charge." When an item or service is determined to be coverable under Medicare, it is reimbursed at 80% of the "reasonable charge" for that item or service, the patient is responsible for the remaining 20%. Unfortunately, the "reasonable charge," a rate set by Medicare, is often substantially less than the actual charge. The result of the "reasonable charge" reimbursement system is that Medicare payment, even for items and services covered by Part B, is often inadequate. The patient is left with out-of-pocket expenses.

When a physician accepts "assignment," he or she agrees to accept the Medicare approved amount as full payment. Medicare will pay 80% and the patient will pay the 20% co-payment. When a physician does not accept assignment the patient is liable for the co-payment plus a balance above the Medicare fee schedule amount. However, under federal law there is a set limit as to the amount a physician may balance bill. A physician may balance bill only 115% of the Medicare fee schedule amount. For example, assume that you go to a doctor who does not accept assignment; his actual charge may be $100, but the Medicare fee schedule is only $70. The doctor may only bill you 115% of the fee schedule amount or $80.50. If the doctor bills above $80.50 he is violating federal law.

Connecticut Information:

Many Connecticut senior centers and Social Security offices have lists of Connecticut physicians and medical equipment suppliers who accept Medicare assignment. Also, the State Department of Social Services, Elderly Services Division has a list and will assist in finding the names of physicians who accept assignment in specific areas. If the patient's physician is not on the list, encourage him or her to accept assignment.

Connecticut residents may be eligible for the State's mandatory Medicare assignment program, ConnMAP. This program requires Part B providers to accept assignment for Connecticut citizens of limited income. Applications are available at most senior centers and at the Connecticut Department of Social Services, Elderly Services Division in Hartford.

Connecticut citizens who are at least 65 years old or who are disabled may also qualify for the State's prescription drug program, ConnPACE. If they have quite low incomes, the State of Connecticut will pay for part of the cost of eligible patient's prescription drugs. Again, applications are available at most senior centers and at the State Department of Social Services, Elderly Services Division in Hartford. NOTE: Patients eligible for ConnPACE are automatically eligible for ConnMAP.


DIABETES SELF-MANAGEMENT TRAINING (DSMT)

WHEN SHOULD MEDICARE COVERAGE BE AVAILABLE FOR DIABETES SELF-MANAGEMENT TRAINING? A QUICK SCREEN FOR IDENTIFYING COVERABLE CASES

WHO'S COVERED

A beneficiary who has had any one of the following medical conditions within the twelve month period preceding the orders for the training:

  • New onset diabetes;

  • Poor glycemic control (HbA1C of $9.5 within 90 days of training);

  • Change in treatment regimen from no medication to medication or from oral medication to insulin;

  • High risk for complications based on poor glycemic control; documented acute episodes of severe hypo- or hyperglycemia within the past year necessitating third party assistance for emergency room visit or hospitalization;

  • High risk based on one of the following documented complications: lack of feeling in the foot or other foot complications; pre-proliferative or proliferative retinopathy, or prior laser treatment of the eye; kidney complications related to diabetes.

Note: Beneficiaries who are inpatients in a hospital, skilled nursing facility, hospice or nursing home are not eligible for services under this benefit, as it must be provided in an outpatient setting.

WHAT'S COVERED

  • Initial Training: up to ten hours within 12 months to provide individuals with necessary skills (including skill to self-administer injectable drugs) and knowledge to participate in the management of his or her own condition.

  • Follow-up Training: up to one hour each year.

CONDITIONS FOR COVERAGE

  • Physician's or qualified non-physician practitioner's orders.

  • Plan of care (POC) which includes content, number, frequency and duration of services.

  • Services reasonable and necessary for treatment of diabetes (certification on POC).

  • Group training if available within two months of doctor's orders.

  • Certified provider (may include physicians, individuals or entities that meet the applicable standards of the National Diabetes Advisory Board, or that are recognized by an organization that represents individuals with diabetes as meeting standards for furnishing the services).

PAYMENT AMOUNT DETERMINATIONS

Payment for DMST services will be made under the Medicare Part B physician fee schedule.

BLOOD GLUCOSE MONITORS AND BLOOD TESTING STRIPS

These will be covered without regard to whether the beneficiary has Type I or Type II diabetes or whether or not the beneficiary uses insulin. Blood testing strips and blood glucose monitors will be classified as durable medical equipment, and payment for the blood-testing strips will be reduced by 10 percent.

  • Monitors with voice synthesizers are covered for patients with bilateral best corrected visual acuity of 20/200 or worse.

  • The most regularly consumed supplies are the test strips and lancets used in conjunction with the glucose monitor. Generally, coverage is available for up to 100 lancets and 100 test strips every 3 months for a non-insulin dependent diabetic and 100 lancets and 100 test strips every month for an insulin dependent diabetic.

  • When greater than the usual quantities are required to assure appropriate glycemic control, the physician must document in the patient's medical record the reasons for the higher than usual testing frequency. The patient must forward to the supplier a log of test results corroborating higher testing frequency. Suppliers must receive a written order from the physician before they may submit claims to Medicare for reimbursement.

  • The physician must see and evaluate the patient within 6 months prior to ordering (and renewing prescriptions for) higher than usual quantities.

For more information Visit the Diabetes Association Website at http://diabetes.org/.


MEDICAL NUTRITION THERAPY SERVICES (MNT) FOR BENEFICIARIES WITH DIABETES OR RENAL DISEASE

Pursuant to § 105 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), as of January 1, 2002, medical nutrition therapy services are available for beneficiaries with diabetes or renal disease.

WHO'S COVERED

  • A beneficiary with diabetes, which is defined as diabetes mellitus Type I (an autoimmune disease that destroys the beta cells of the pancreas, leading to insulin deficiency) and Type II (familial hyperglycemia). The diagnostic criterion for a diagnosis of diabetes is a fasting glucose greater than or equal to 126 mg/dl. These definitions come from the Institute of Medicare 2000 Report, The Role of Nutrition in Maintaining Health in the Nation's Elderly.

WHAT'S COVERED

  • An initial visit for an assessment; follow-up visits for interventions; and reassessments as necessary during the 12 month period beginning with the initial assessment ("episode of care") to assure compliance with the dietary plan.

  • A specific, maximum number of hours will be reimbursable in an episode of care. The maximum number of hours will be set forth in a future Center for Medicare and Medicaid Program Memorandum.

  • The number of hours covered for diabetes may be different than the number of hours covered for renal disease.

CONDITIONS FOR COVERAGE

  • The treating physician must make a referral and indicated a diagnosis of diabetes or renal disease.

  • Services may be provided either on an individual or group basis without restrictions.

  • When follow-up Diabetes Self-management Tranining (DSMT) and Medical Nutrition Therapy (MNT) services are provided within the same time period, hours from both benefits will be counted toward the maximum number of covered hours allowed during the episode of care.

  • MNT services must be provided by a professional as defined below.

LIMITATIONS ON COVERAGE

  • MNT services are not covered for beneficiaries receiving maintenance dialysis for which payment is made under § 1881 of the Act.

  • If a beneficiary has both renal disease and diabetes, they may receive only the number of hours covered under this benefit for either renal disease or diabetes, whichever is greater.

  • A beneficiary cannot receive MNT if they have received an initial DSMT within the last 12 months unless the need for reassessment and additional therapy has been documented by the treating physician as a result of a change in diagnosis or medical condition or the beneficiary receiving DSMT is subsequently diagnosed with renal disease.

  • If a beneficiary diagnosed with diabetes has been referred for both follow-up DSMT and MNT services, the number of hours the beneficiary may receive is limited to the number of hours covered under either follow-up DSMT or MNT services annually, whichever is greater.

CERTIFIED PROVIDER

For Medicare Part B coverage of MNT, only a registered dietitian or nutrition professional may provide the services. This must be an individual licensed or certified in a State as of December 21, 2000; or an individual whom, on or after December 22, 2000:

  • Holds a bachelor's or higher degree granted by a regionally accredited college or university in the united States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics, as accredited by an appropriate national accreditation organization recognized for this purpose;

  • Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and

  • Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of the first two bullets of this section.

PAYMENT FOR MEDICAL NUTRITION THERAPY

Payment will be made under the Medicare Part B physician fee schedule for dates of service on or after January 1, 2002, to a registered dietitian or nutrition professional that meets the above requirements. Part B deductible and co-insurance rules apply. As with the DSMT benefit, payment is only made for MNT services actually attended by the beneficiary and documented by the provider and for beneficiaries that are not inpatients of a hospital or skilled nursing facility.


THE OUTPATIENT PROSPECTIVE PAYMENT SYSTEM

As of August 1, 2000, Medicare changed the way it pays for outpatient hospital and community health center services. This system, called the outpatient prospective payment system (OPPS), changed how much Medicare beneficiaries pay and how much Medicare pays for outpatient services, such as emergency room visits or one day surgery services. This payment system was one of the many changes made by the Balanced Budget Act of 1997 (BBA).

Under OPPS, the beneficiary must continue to pay the Part B deductible ($110 per year in 2005) and, depending upon the service received, either a 20% coinsurance amount (as before the BBA) or a fixed co-payment amount for each service. The fixed co-payment amount is determined by taking into account a number of factors including the national median charge for the particular service received and the hospital wages in which the service was provided.

Depending upon what service was received and what hospital provided the service, the beneficiary's out-of-pocket costs may be higher than they were before the BBA for the same service. Hospitals may choose to lower the fixed co-payment amount for a particular service to a minimum of 20% but if they do, they must keep the lower co-payment for one calendar year and they must charge all Medicare patients that lower amount.

The Medicare, Medicaid and SHIP Benefit Improvement and Protection Act of 2000 (BIPA) places a cap of 57% on the fixed co-payment amount for services received after April 1, 2001. That cap will be incrementally lowered each year until it reaches 40% for services received in the year 2006 and thereafter. Medigap insurance will still cover co-insurance amounts. If the beneficiary has a Medigap policy that covered out-of-pocket costs before the BBA changes, the same policy should also cover the out-of-pocket costs under the new payment system.

Medicare does not pay for all outpatient department services under the new prospective payment system. For example, Medicare continues to pay for clinical diagnostic laboratory services, ambulance services, dialysis and outpatient therapy under the old system. In addition, Medicare will not pay at all for some surgical procedures if they are given on an outpatient basis (for example, fixing a fractured hip). Even if the beneficiary can get these services on an outpatient basis, Medicare considers them inpatient services and will not pay for them on an outpatient basis. Beneficiaries should check with their hospital or doctor to make sure that Medicare will pay for the procedure they are receiving on an outpatient basis.


MEDICARE COVERAGE OF HOME OXYGEN THERAPY

Medicare provides for coverage of home oxygen therapy under the Part B durable medical equipment benefit. This coverage includes the rental of the oxygen delivery system and the cost of oxygen itself, including portable units. On October 1, 1985, the Health Care Financing Administration (HCFA) established rigid coverage criteria requiring patients to demonstrate medical necessity through specific laboratory evidence. HCFA requires that medical necessity be established through arterial blood gas (ABG) studies. When ABG studies are not available or medically contraindicated, oxygen saturation levels may be determined by ear oximetry readings. However, HCFA and Medicare Part B carriers discourage the use of oximetry testing.

The coverage criteria creates three categories:

1) An ABG-PO2 at or below 55 or oxygen saturation at or below 88%, is presumed to establish coverage,

2) An ABG-PO2 at 56-59 or oxygen saturation at 89% will establish coverage if one of three specified conditions are also shown, these include:

• Dependent edema suggesting congestive heart failure, or

• Pulmonary hypertension, or cor pulmonale, or

• Erythrocythemia with a hematocrit › 56%

3) An ABG-PO2 at 60 or above or oxygen saturation at or above 90% creates a presumption that oxygen is not medically necessary.

Although it is stated that the presumption is rebuttable, in practice HCFA automatically denies coverage for anyone who does not meet the ABG or oximetry standards.

The oxygen coverage criteria have been established as a national coverage determination which is codified at Section 60-4 of the Medicare Coverage Issues Manual (HCFA Pub.-6). This means that the restrictive coverage criteria are binding on all coverage determinations from the initial decision through an ALJ hearing. See, 42 U.S.C. § 1395ff(b)(3)(A).


OUTPATIENT THERAPY SERVICES

A QUICK SCREEN TO AID IN IDENTIFYING COVERABLE CASES

Physical, Speech and Occupational Therapy services are suitable for Medicare Part B coverage, and appeal if they have been denied, if they meet the following criteria:

1. The services were ordered, and the orders are periodically reviewed, by the patient's treating physician.

2. The services are "medically necessary." This means that the services provided are considered a specific and effective treatment for the patient's condition under accepted standards of medical practice.

3. The services are sufficiently complex, or the condition of the patient is such, that the services required can be safely and effectively performed only by, or under the supervision of, a qualified therapist. (Services which do not require the performance or supervision of a skilled therapist are not coverable, even if they are in fact performed or supervised by a skilled therapist.)

OTHER IMPORTANT POINTS

  • Many Medicare denials are based on the lack of expectation of a significant improvement in the patient's condition within a reasonable and predictable period of time. However, "restoration potential" is not required by law and a maintenance program can be covered if skilled services are necessary to prevent further deterioration or preserve current capabilities.

  • Services that can ordinarily be performed by non-skilled personnel should be considered skilled services if, because of medical complications, a skilled therapist is required to perform or supervise the services.

  • The doctor is the patient's most important ally. If it appears that Medicare coverage will be denied, ask the doctor to write stating that the standards described above are met. Attach this statement to any Medicare claim submission or appeal. (Keep a copy for your records.)

  • Don't be satisfied with a Medicare determination unreasonably limiting care or coverage; appeal for the benefits the patient deserves. It will take some time, but you will probably win your case.

IMPORTANT NOTE ABOUT PAYMENT: The Balanced Budget Act of 1997 instituted an annual Medicare payment cap on outpatient physical, speech, and occupational therapy services. This cap quickly became a problem for many beneficiaries with long term conditions. A moratorium was placed on the cap, and extended through December 31, 2002 by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 placed another 2-year moratorium on the Medicare payment cap on outpatient physical, speech, and occupational therapy services. HOWEVER, because no legislation was passed to address the caps prior to the end of 2005, the THERAPY PAYMENT CAPS ARE IN PLACE.

For 2014, the cap amounts are $1920.00 for physical therapy and speech therapy combined, and another $1920.00 for occupational therapy. The cap does not apply to therapy services furnished in hospital-based outpatient departments.

Additional Information:


PHYSICIANS' FEES: MEDICARE LIMITS ON CHARGES

When an item or service is determined to be coverable under Medicare Part B, it is reimbursed at 80% of a payment rate approved by Medicare, known as the "approved charge." The patient is responsible for the remaining 20%. Unfortunately, the "approved (or "reasonable") charge," is often substantially less than the actual charge. The result of this reimbursement system is that Medicare payment, even for items and services covered by Part B, is often inadequate. The patient is left with out-of-pocket expenses. When a physician accepts "assignment," he or she agrees to accept the Medicare approved charge as full payment for the services provided. Medicare pays 80% of the approved charge. Either the patient or supplemental insurance pays the remaining 20% co-payment. No further payment is due to the physician.

When a physician does not accept assignment, however, he or she may "balance bill" the patient above the Medicare approved charge. "Balance bill" refers to a physician's charge above the Medicare approved rate. Federal law sets a limit known as the "Limiting Charge" on the amount a physician may balance bill. The Limiting Charge is based upon a percentage of the Medicare approved charge for physician services.

Generally, a physician who does not accept assignment may not charge a total of more than 115% of the Medicare approved amount. The patient's Explanation of Medicare Benefits (EOMB), the written notice which is sent to patients after a Medicare claim is processed, will state the approved charge for the doctor's services. The Limiting Charge should be listed on the EOMB; if it is not the patient can calculate it by multiplying the Medicare approved charge by 115%.

For example, assume the patient goes to a doctor who does not accept assignment. The doctor's actual charge is $600, but the Medicare approved charge allows only $349.37. The doctor's total bill may not exceed $401.89 (115% x $349.47); this is the Limiting Charge. Medicare will pay $279.50 (80% of the $349.37 approved charge). The physician cannot charge the patient more than $122.39 ($401.89 minus Medicare payment of $279.50). If the doctor bills above $401.89 he is billing above the Limiting Charge and is violating federal law.

Again, a Medicare beneficiary is usually correct in assuming that the Limiting Charge is 115% of the approved charge noted on the EOMB; the actual limiting charge will be stated on the EOMB. In a few instances it will be more or less than 115% of the approved charge. If this seems to be the case, or if other questions arise, you can obtain specific Limiting Charge information by calling United Health Care at 1-800-982-6819. If you have any questions or trouble obtaining Limiting Charge information, please call the Center for Medicare Advocacy at 1-800-262-4414.

Important Note: As of September 1990 all Medicare Part B providers must submit claims directly to Medicare on behalf of their Medicare patients.


MEDICARE PREVENTIVE BENEFITS

Quick Reference Chart

MEDICARE COVERED PREVENTIVE SERVICES INCLUDE: (see below for further details)

  • Initial Preventive Physical Examination (IPPE)
  • Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
  • Cardiovascular Disease Screenings
  • Diabetes Screening Tests
  • Diabetes Self-Management Training (DSMT)
  • Human Immunodeficiency Virus(HIV) Screening Tests
  • Medical Nutrition Therapy (MNT)
  • Screening Pap Tests
  • Screening Pelvic Exam
  • Screening Mammography
  • Bone Mass Measurements
  • Colorectal Cancer Screening
  • Prostate Cancer Screening
  • Glaucoma Screening
  • Smoking and Tobacco-Use Cessation Counseling
  • Influenza Virus Vaccine
  • Pneumococcal Vaccine
  • Hepatitis B (HBV) Vaccine

INITIAL PREVENTIVE PHYSICAL EXAMINATION

The IPPE is also known as the "Welcome to Medicare Physical Exam" or "Welcome to Medicare Visit." All Medicare beneficiaries are entitled to it when fist eligible for Medicare Part B on or after January 1, 2005. The benefit is available only once in the lifetime of a beneficiary. The IPPE must be furnished no later than 12 months after the effective date of initial Medicare Part B coverage. Co-payments apply. There is a deductible for the IPPE received prior to January 1, 2009. No deductible applies for the IPPE received on or after January 1, 2009; however, a deductible can be charged for a screening EXG and its interpretation which are considered optional services that may be performed as a result of a referral from an IPPE.

ANNUAL SCREENING MAMMOGRAPHY

Medicare will cover annual mammograms for female beneficiaries age 40 and over. The Part B annual deductible is waived for these services.

SCREENING PAP SMEAR AND PELVIC EXAM

Medicare will cover one pelvic exam, including a clinical breast exam, and pap test every two years. Women who are at high risk for cervical cancer can have these tests covered on an annual basis. The Part B annual deductible is waived for these services.

COLORECTAL CANCER SCREENING

Medicare will cover the following colorectal cancer screening tests:

  • one screening fecal-occult blood test every year for individuals over age 50;
  • one screening flexible sigmoidoscopy every 4 years for individuals over age 50;
  • one screening colonoscopy every 2 years for high risk individuals, and
  • other tests, procedures and modifications as Medicare finds appropriate.

COLONOSCOPY SCREENING

Certain colonoscopy screening once every 10 years or within 4 years of screening flexible sigmoidoscopy.

DIABETES SELF-MANAGEMENT TRAINING

Medicare will cover outpatient diabetes self-management training services if the physician who is managing the individual's diabetic condition certifies that the services are needed under a comprehensive plan of care to provide the individual with necessary skills and knowledge to participate in the management of the individual's condition.

DIABETES SCREENING TESTS

Medicare will provide coverage for home blood glucose monitors and testing strips for all diabetics without regard to a person's use of insulin. Medicare does not cover syringes or insulin.

Coverage of diabetes screening tests provides for a fasting plasma glucose test (other tests as the Secretary deems appropriate) and is limited to individuals at high risk for diabetes. This is defined as having any of the following risk factors – htn, dyslipidemia, obesity (BMI>30), previous identified impaired glucose tolerance, OR at least two of the following: overweight (BMI 25 – 30), family history of DM, history of gestational DM or delivery of baby > 9 lbs., age 65 or older. Frequency covered is no more than twice per year.

HUMAN IMMUNODEFICIENCY VIRUS (HIV) SCREENING TESTS

On December 8, 2009 the Centers for Medicare & Medicaid Services (CMS) announced its final decision to cover Human Immunodeficiency Virus (HIV) infection screening for Medicare beneficiaries who are at increased risk for the infection, including women who are pregnant and Medicare beneficiaries of any age who voluntarily request the service. More information about Medicare's new HIV screening benefit is available in CMS' final decision memorandum at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6786.pdf.

CHOLESTEROL TEST

Coverage of cardiovascular screening blood tests covers a cholesterol (lipids and triglycerides) test once every two years at most.

BONE MASS MEASUREMENT

Medicare will cover bone mass measurement procedures for the following high-risk persons:

  • an estrogen-deficient woman at clinical risk for osteoporosis;
  • an individual with vertebral abnormalities;
  • an individual receiving long-term glucocorticoid steroid therapy;
  • an individual with primary hyperparathyroidism;
  • an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy.

PROSTATE CANCER SCREENING TESTS

Medicare will cover an annual prostate cancer screening test for men over age 50. The test could consist of any (or all) of the following procedures:

  • a digital rectal exam;
  • a prostate-specific antigen blood test; and
  • other procedures as Medicare finds appropriate for the purpose of early detection of prostate cancer.

GLAUCOMA SCREENING

Glaucoma Screening for persons at risk of glaucoma (includes those with family history of glaucoma or with diabetes).

MEDICAL NUTRITION THERAPY

Medical Nutrition therapy services for patients with diabetes or kidney disease.

SMOKING AND TOBACCO USE CESSATION COUNSELING

Covers two individual tobacco cessation counseling attempts per year. Each attempt may include up to four sessions, with a total annual benefit thus covering up to eight sessions per Medicare patient who uses tobacco.

COVERAGE CONTINUES TO BE AVAILABLE FOR:

  • Influenza vaccines;
  • Pneumococcal vaccines;
  • Hepatitis B vaccine.

Additional Information:

  • Note about payment: While Medicare coverage is available for the above services, payment may not cover all the costs due to the Medicare Outpatient Payment System. Contact your provider for specific details.
  • The Centers for Medicare and Medicaid Services (CMS) released a revised quick reference chart of Medicare's Preventive services in October 2013 , through its "MedLearn" series. The chart enumerates the several preventive benefits available under the traditional Medicare program, beneficiary eligibility, frequency of coverage, and applicable co-payments and deductibles. The chart also provides useful coding information which can be relevant when there are billing issues. See http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf.

Items Not Normally Covered Under Medicare

  • Dental Services

Medicare coverage of dental services is limited.  Over the years, litigation and other efforts to clarify and expand Medicare’s coverage of dental services have not been successful.  At best, non-routine dental services, in association with exacerbating medical conditions, have sometimes garnered coverage following lengthy appeals.

 

Medicare Statute

 

The Medicare statute excludes coverage of dental services in the following language: 

No payment may be made [by Medicare] . . . for any expenses incurred for items or services – . . . where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth . . .  42 U.S.C. § 1395y(12).

 

This language excludes coverage of ordinary dental services, and Congress placed it in a section of the Medicare statute that excludes coverage of a number of other medical services that are generally considered to be routine, For this reason, the Medicare statute can be read as allowing coverage of dental services that are not "routine," such as the special care necessitated by the effects of radiation and chemotherapy treatments prescribed to treat oral, head and neck cancer.

 

Medicare Agency Policy

 

The Medicare Benefits Policy Manual (MBPM), CMS Pub 100-02 at https://www.cms.gov/Regulations-and-Guidance/Guidance/manuals/, allows for exceptions to the usual exclusion of dental services.  It specifies that a service should be covered if it is "incident to and an integral part of a covered service performed by the dentist."  An application of this "incident to and an integral part of" rule that is provided in the Manual is reconstruction of a ridge that can be used to prepare the mouth for dentures if it is done at the same time as surgical removal of a tumor, but not if it occurs afterwards. MBPM, Chap. 15, § 150.

 

The MBPM also allows Medicare coverage of certain other dental services that are related to cancer treatment.  For example, Medicare will cover the extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.  However, the MBPM manual warns that coverage of such extractions is an exception to the usual rule that the dental service must be "incident to and an integral part of a covered procedure or service performed by the dentist."   MBPM, Chap.16, § 140.  Coverage of such an extraction is considered an exception because the extraction does not occur simultaneously with the radiation treatment.  Thus, the Centers for Medicare & Medicaid Services (CMS) admits that the "incident to and an integral part of" requirement is not applied consistently.

 

Increasing the Possibilty of Coverage

 

The likelihood of obtaining Medicare coverage for non-routine dental care can be increased by taking certain steps.  First, a treatment plan established at the outset by the primary physician providing covered medical services should include provision for ancillary dental care.  As dental services are needed, the physician should state that the services are incident to and necessary for the patient's primary treatment, and prescribe the specific dental services.  This will take such dental services out of the exclusion for routine care, and show that they are "incident to and an integral part of" a covered course of treatment.

 

In order to obtain a successful decision, it may be necessary for the beneficiary to go through a number of unsuccessful lower levels of administrative appeal before reaching the ALJ or federal court levels.  At these higher levels of appeal, the beneficiary or her advocate will have an opportunity to overcome the presumption that Medicare never covers dental services.   Testimony and medical records from the beneficiary's physicians should be presented to show that the dental services were ordered and supervised by them as part of the claimant's covered treatment.   Legal arguments can be made that 1) the controlling Medicare statute, as shown by its legislative history, excludes only coverage of routine dental services; 2) the manual requirement that services be "incident to and an integral part of" covered services was met; or if not met, 3) the interpretations of the statute in the manual are too inconsistent and unreasonable to be given deference.

 

Additional Resources

The Medicare Statute Excludes Coverage of "Routine" Eyeglasses

When Congress established the Medicare program in 1965 it excluded coverage of certain items and services it believed were routinely needed and low in cost.  Such excluded items included physical examinations, drugs, hearing aids, dental services, and eyeglasses.  The statute still excludes payment for most eyeglasses, in the following language:

where such expenses are for routine physical checkups, eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of  prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examinations) to determine the refractive state of the eyes, hearing aids or examinations therefore, or immunizations (except as otherwise allowed under section 1861(s)(10) and subparagraph (B), (F), (G), (H), or (K) of paragraph (1)).

The exception to the eyeglass exclusion mentioned here is for "prosthetic devices . . . including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens." 

The Medicare regulations parrot the limitations on coverage of eyeglasses in the Medicare statute.

The Centers for Medicare & Medicaid Services (CMS) Allows Coverage of Some Optical Devices in Its Policy Manuals

The Medicare Benefit Policy Manual, Pub. 100-02 (MBPM) elaborates on the primary statutory exception to the exclusion of eyeglasses, which is eyeglasses or contact lenses following cataract surgery.  In addition to the intraocular lens inserted during the surgery, the policy allows coverage after surgery for:

1. prosthetic bifocal lenses in frames; 2. prosthetic lenses in frames for far vision and prosthetic lenses in frames for near vision; 3. when prosthetic contact lenses for far vision have been prescribed, those contact lenses plus prosthetic lenses in frames for near vision and prosthetic lenses in frames for when the contacts have been removed; and 4. lenses with ultraviolet absorbing or reflecting qualities if medically reasonable and necessary.  

While Medicare covers post-surgical eyeglasses, it will pay for only standard frames.  It allows the patient to be charged the difference between the cost of standard frames and deluxe frames, if chosen by the patient.  The program does not cover cataract sunglasses.  Furthermore, Medicare does not cover the cost of the refractive services necessary to prescribe post-surgical eyeglasses under the general exclusion of such services in the statute.

Although intraocular lenses (IOLs) inserted during cataract surgery are covered under the statute, Medicare policy denies coverage for astigmatism-correcting IOLs that combine the functions of conventional IOLs and post-surgical prosthetic eyeglasses, (which are covered).  CMS has also denied coverage of IOL models not fully approved by the FDA.

The Center for Medicare and Medicaid Services (CMS) issues National Coverage Determinations (NCDs) that are binding in decisions on claims up to the Administrative Law Judge level of appeal.  The Medicare NCD Manual allows coverage of some technologies that serve optical functions but are deemed not to fall into the category of routine eyeglasses.  It provides that hard contact lenses (scleral shells or shields) used as artificial eyes or in treating dry eye with artificial tears are covered. CMS has also stated that hydrophilic (soft) contact lenses used as bandages for the treatment of corneal pathology such as dry eyes, corneal ulcers and erosion, etc. will be covered by Medicare. Although hydrophilic contact lenses are covered as treatment when prescribed for patients lacking the eye's natural lens ("aphakic" patients), they are categorized by CMS as non-covered eyeglasses within the exclusionary language of the Medicare statute when used to treat nondiseased eyes with spherical ametrophia, refractive astigmatism, and/ or corneal astigmatism.

  • Hearing Aids

The exclusion of some hearing aids is specified in the Medicare statute, which states that payment is prohibited:

where such expenses are for routine physical checkups, eyeglasses . . . or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed . . . to determine the refractive state of the eyes, hearing aids or examinations therefore,…

Despite this indication that the coverage exclusion applies only to hearing aids needed in routine situations, the Medicare regulations do not limit the exclusion of hearing aids.  Coverage is excluded broadly, for: 

(d) Hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids.

The Medicare policy manual, which controls initial decisions on coverage that are made by the Medicare claims processing contractors, excludes coverage of all hearing aids. It states:

Hearing aids are amplifying devices that compensate for impaired hearing.  Hearing aids include air conduction devices that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound.  They also include bone conduction devices that provide mechanical energy to the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.

Although hearing aids are not covered, the policy manual does allow Medicare coverage of prosthetic devices to aid hearing in certain circumstances.  Prosthetic devices are defined as "devices that produce perception of sound by replacing the function of the middle ear, cochlea or auditory nerve."[5]  The following are considered by Medicare to be prosthetic devices:

Cochlear implants and auditory brainstem implants, i.e., devices that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays. 

Osseointegrated implants, i.e., devices implanted in the skull that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.

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