The Medicare Benefit Policy Manual: Everything You Need to Know

The Centers for Medicare & Medicaid Services’ (CMS) Medicare Benefit Policy Manual, known as Publication 100-02, is an important guidebook for anyone operating in the world of Medicare, whether medical professionals, administrators, or beneficiaries. It makes it possible to thoroughly understand a complex Medicare landscape and is the go-to resource for formulating and carrying out Medicare policy.

The Medicare Benefit Policy Manual is a trusted resource for

comprehending eligibility requirements
navigating the complicated structure of coverage requirements
processing claims
understanding the technicalities of reimbursement.

The guide gives healthcare professionals the information they need to decide on patient care in an informed manner, ensuring that procedures and services are carried out in conformity with Medicare regulations. Further, it provides clarity in the otherwise complex world of billing and reimbursement, thereby encouraging more effective and efficient healthcare delivery.

This manual’s main focus is on Part A benefits of Medicare. It includes sections covering a variety of topics, including:

Coverage for inpatient psychiatric treatment
Skilled nursing institutions
Hospice care
Ambulance services
The distribution of lifetime reserve days
Home health care.

The Medicare Benefit Policy Manual also gives beneficiaries what they need to access their Medicare-related rights and benefits. As a result, they can make informed decisions about their health in a world of complicated medical terminology and healthcare options. The manual promotes a sense of agency and guarantees they get the treatment they are entitled to.

Medical professionals may find Chapters 8 and 15 of the Medicare Benefit Policy Manual to be challenging to understand, especially concerning reimbursement processes. These chapters contain thick, technical language and constantly changing rules. So healthcare practitioners need to invest a lot of time and energy to understanding them to ensure correct reimbursement for services performed.

Here we offer a brief overview of Chapters 8 and Chapter 15 given their central position in the Medicare Benefit Policy Manual. We will look into the necessity of studying them and highlight the most important points. Meanwhile, to access the complete list of chapters from the Medicare Benefit Policy Manual on the CMS website, click here.

Medicare Benefits Policy Manual Chapter 8

The Medicare Benefit Policy Manual’s Chapter 8 lists the requirements for Medicare’s Hospital Insurance coverage of extended care services provided in skilled nursing facilities (SNFs). These requirements must be met for Medicare to cover SNF stays and the services supplied to beneficiaries.

What’s covered in a SNF under Chapter 8?

Extended care services include numerous amenities that are offered to SNF inpatients either directly or through agreements, such as:

Nursing care
Bed and board
Therapy services
Medical social services
Prescriptions
Supplies

What are the conditions for receiving care under Chapter 8?

The “3-day rule” and the specific kind of care that SNFs must provide to qualify for coverage are important components of Chapter 8. The following criteria are listed in The Medicare Benefit Policy Manual Chapter 8, Section 30, which states that for a patient to be eligible for Medicare Part A coverage in an SNF setting, they must:

Be transferred to an SNF within 30 days of hospital discharge
Have had a minimum of three consecutive calendar days of medically necessary hospitalization before being eligible for these services
Have an ailment that was either managed during the qualifying hospital stay or that developed while receiving care in the SNF for a condition that had already been managed in the hospital

Need, according to a physician, skilled nursing or skilled rehabilitation services that require the experience of professional or technical employees
Require these specialized services regularly
Have no reasonable option but to receive these daily skilled services in a SNF due to practicality, efficiency, and economy

What is the 30-day rule for Chapter 8?

The timing of a patient’s application for extended care services at a skilled nursing facility (SNF) is important. The patient must transfer to a SNF within 30 days of being discharged from the hospital. For example, a patient satisfies the 30-day criterion if they are released from the hospital on August 1 and admitted to an SNF on August 31. But if a patient does not need a covered level of care until more than 30 days later, they do not qualify for coverage.

On the other hand, even if Medicare coverage doesn’t start right away, the patient can still meet the timely transfer criteria as long as they need and begin the covered level of treatment in the SNF within the allotted timeframe. So Medicare payment can kick in later if another payment source initially covers the SNF stay.

The section also makes clear that, if a patient goes more than 30 days without needing a covered level of care, they will need a new qualifying hospital stay to receive Medicare coverage of extended care services. Exceptions, of course, apply.

How are outside services covered?

The regulation also covers agreements signed by skilled nursing facilities (SNFs) with outside suppliers or providers. Because of this, Medicare beneficiaries can receive approved treatments like physical therapy, occupational therapy, or speech-language pathology services. Here are some common questions about using outside providers and suppliers:

Who is responsible for billing? When an SNF makes arrangements for these covered services through outside suppliers or providers, the SNF is in charge of billing Medicare directly, and payment is provided to the SNF directly. The beneficiary or any other party is released from the duty to make separate payments for these services under this agreement.

What is the payment arrangement? The particular terms of the payment arrangement, including payment amounts and due dates, between the SNF and the outside supplier are arranged as private, market transactions between the parties.
What other laws must be observed? These agreements must abide by fraud and abuse laws, which include anti-kickback clauses. To ensure that the agreements are legitimate under the law, compliance with these laws is necessary.
What do we need to know about anti-kickback provisions? The Industry Guidance Branch in the Office of the Inspector General (OIG) at HHS should be contacted with any questions regarding the application and interpretation of the statutory anti-kickback provisions in section 1128B(b) of the Social Security Act. The OIG website also has more information, and 42 CFR Part 1008 contains detailed regulations on this subject.

Medicare Benefits Policy Manual Chapter 15

The general information on therapy treatments that are covered by Medicare is outlined in Chapter 15 of the Medicare Benefits Policy Manual, which is entitled “Covered Medical and Other Health Services”. Here is a short summary of the key points from Medicare Benefit Policy Manual Chapter 15:

Coverage: Under certain parts of the Social Security Act (1861(g), 1861(p), and 1861(ll)), therapy services are covered as benefits. They may also count as medical or non-medical practitioner services in accordance with sections 1861(s)(2) and 1862(a)(20).
Providers: A variety of providers and their affiliates as well as suppliers—including doctors, non-physician practitioners, and enrolled therapists—may offer covered therapy services so long as they meet Medicare’s requirements for therapy services.
Payment: Therapeutic services that satisfy PPS conditions are compensated when a prospective payment system (PPS) is in place. The corresponding PPS rates include reimbursement for therapy given to hospital inpatients or residents of skilled nursing facilities (SNF) during covered stays.
Home Health: Therapy services can be billed by home health agencies (HHAs) under certain circumstances. In such cases, payment is already counted as part of the home health PPS rate. It’s also possible to bill as therapy services if there is a proper therapy plan of treatment and home health services aren’t billed under a home health plan of care.
Regulations: Therapy services must follow the health and safety rules outlined in 42 CFR 484 and 42 CFR 485 in addition to the standards stated in this chapter.
Community Pool Usage: Clinicians, private physical therapy or occupational therapy practices, doctor’s offices, outpatient hospitals, and outpatient SNFs may rent or lease a communal pool (or a specific area of it) for the purpose of conducting therapy services. Of course, patients of that particular practice or physician are only permitted to utilize the pool during defined hours. And the rental or leasing agreements for the pool should be available for inspection upon request.
Provider Types: When renting or leasing community pools, state operations manual regulations apply to the providers, like rehabilitation agencies.

Medicare benefit policy manual chapter 15, section 220

Section 220 of Chapter 15 is entitled “Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance”. This section provides information related to outpatient therapy episodes. Here are the key points of section 220:

Definition of an Outpatient Therapy Episode: Section 220 defines an outpatient therapy episode as the period of time (calendar days) during which a patient is under the care of a clinician (like a physical therapist, occupational therapist, or speech-language pathologist) for a specific condition. The episode encompasses evaluation and treatment for that condition. The section also mentions that the episode can cover multiple conditions, even those that arise after the episode has commenced.
Example of Section 220: To illustrate this concept, the document provides an example of a patient receiving physical therapy for a hip fracture and later developing lower back pain. The treatment for both the hip fracture and the lower back pain falls under the same episode of physical therapy care. However, if the patient develops a swallowing problem during intubation for the hip surgery, the first day of treatment by the speech-language pathologist (SLP) constitutes a new episode of SLP care.
Implications for Billing: The section makes clear that therapists and healthcare providers need to categorize treatments within these episodes accurately to ensure proper billing and adherence to Medicare guidelines.

Chapter 15, Section 10: Medicare Part B coverage

The terms and criteria described in The Medicare Benefit Policy Manual for Medicare Part B coverage of outpatient therapy services are broken down as follows:

You can find specific details about some aspects of Part B coverage in Medicare Benefits Policy Manual Chapter 15.

Coverage for Therapy Services: Part B of Medicare provides coverage specifically for therapy services. Payment is made only for services that qualify as therapy. If there is any uncertainty about whether a service falls under the category of therapy, local coverage determination (LCD) is made by the contractor in the respective area.

Coverage Criteria: For a service to be covered, it must meet certain criteria:
- It must fall within a benefit category defined in the statute.
- It must not be excluded.
- It must be reasonable and necessary.

Benefits Category: Therapy services fall under §1861 of the Social Security Act. Additional details on what constitutes a reasonable and necessary service can be found in Pub. 100-08, chapter 13, §13.5.1.

Conditions for Payment: To receive payment for outpatient therapy services, specific conditions must be met, including:
- The individual required therapy services.
- A plan for providing these services was established by a physician, non-physician practitioner (NPP), or therapist, and it was periodically reviewed by a physician or NPP.
- The services were provided while the individual was under the care of a physician.
- Certification was obtained from a physician or NPP for coverage and payment of a therapy claim.

NPI Requirement: Claims for outpatient physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services must include the National Provider Identifier (NPI) of the certifying physician for the respective therapy plan of care.

Functional Reporting: Claims for these therapy services must also contain the relevant functional reporting as specified in the regulations (42 CFR 410.59, 60, and 62). Functional limitations reported on claims should align with the limitations identified in the therapy plan of care and expressed as part of the patient’s long-term goals.

Medicare benefit policy Manual chapter 16

Medicare, the U.S. government’s health insurance program for seniors and certain individuals with disabilities, includes a wide range of coverage for medical services and supplies. However, there are specific goods and services that Medicare often does not cover. These exclusions, outlined in Chapter 16, encompass:

Cosmetic procedures
Routine dental and vision care
Hearing aids
Long-term custodial care
Acupuncture
Certain prescription drugs

While Original Medicare has these limitations, individuals have options to enhance their coverage through supplemental insurance plans like Medigap or Medicare Advantage.

The Medicare Benefit Policy Manual

The Medicare Benefit Policy Manual is a valuable resource that provides thorough explanations for every element of healthcare, even if reading it can be overwhelming at first. By paying careful attention to detail, caregivers will gain access to a wealth of information that helps them ensure they are abiding by the rules of the CMS and maximizing reimbursement at their organization.

For more on recent trends in long-term care, visit our blog.