HI 00610.010 Incurred Expenses

Citations:

Social Security Act, Section 1832

20 CFR 405.230-405.245

SMI includes coverage for expenses incurred in connection with:

A. Physicians' (see HI 00401.295 ) services, including surgery, consultation and home, office, and institutional calls, and services and supplies furnished incident to a physician's professional services;

B. Outpatient hospital services furnished incident to physicians' services;

C. Outpatient diagnostic services furnished by a hospital;

D. Outpatient physical therapy and effective 1/1/73, outpatient speech pathology services;

E. Diagnostic X-ray tests, laboratory tests, and other diagnostic tests;

F. X-ray, radium, and radioactive isotope therapy;

G. Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;

H. Rental or purchase of durable medical equipment for use in the patient's home;

I. Ambulance service;

J. Prosthetic devices which replace all or part of an internal body organ;

K. Leg, arm, back, and neck braces, and artificial arms, legs and eyes;

L. Home health services for up to 100 visits during a calendar year. Effective July 1, 1981, the 100 visit limitation is eliminated.

M. Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies;

N. Rural health clinic services;

O. comprehensive outpatient rehabilitation facility services;

P. certain ambulatory surgical center facility services;

Q. antigens;

R. pneumococcal vaccine and its administration.

Payment for physician services and additional medical and other health services is made on a reasonable charge (see HI 00401.305 ) basis. Payment is made to the beneficiary or to the physician or other party who renders services, depending on whether the itemized bill or the assignment procedure is used. Payment for covered medical insurance services rendered to beneficiaries by participating providers of services (hospitals, SNF's and HHA's) may be made only to the provider. Providers furnishing such medical and other health services (other than L, N, O and P) will be reimbursed by the intermediary on the basis of whichever is lower; the provider's customary charge or the reasonable cost of the covered services.

Clinics as suppliers of outpatient physical therapy and speech pathology services are reimbursed by the carrier on a reasonable cost basis. Intermediaries reimburse other providers of these services.

An organization which furnishes medical and other health services on a prepayment basis may elect to be paid on the basis of reasonable costs in lieu of reasonable charges (see HI 00208.095 ).

Payment may not be made under Part B for services furnished an individual if the individual is entitled to have payment made for those services under Part A. An individual is considered entitled to have payment made under Part A if the expenses incurred were used to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of a request for payment or physician certification.

Membership dues, subscription fees, charges for service policies, insurance premiums, and other payments analogous to premiums which entitle enrollees to services, to repairs or replacement of devices, equipment or parts without charge or at a reduced charge, are not expenses incurred for covered items or services. Examples of such arrangements are memberships in ambulance companies, insurance for replacement of prosthetic lenses, and service contracts for durable medical equipment.