Page 21 - Medicare Benefit Policy Manual

NOTE: The A/B MAC (A), (B), or (HHH), or DME MAC will require evidence that
routine collection efforts include the filing of lawsuits to obtain liens against
individuals’ assets outside the prison and income derived from non-prison sources.

• The State or local entity documents its case with copies of regulations, manual
instructions, directives, etc., spelling out the rules and procedures for billing and
collecting amounts paid for prisoners’ medical expenses. As a rule, the A/B
MAC (A), (B), or (HHH), or DME MAC will inspect a representative sample of
cases in which prisoners have been billed and payment pursued, randomly
selected from both Medicare and non-Medicare eligible. The existence of cases
in which the State or local entity did not actually pursue collection, even though
there is no indication that the effort would have been unproductive, indicates that
the requirement to pay is not enforced.

The CMS maintains a file of incarcerated beneficiaries, obtained from SSA, that is used
to edit claims.

Providers and suppliers that render services or items to a prisoner or patient in a
jurisdiction that meets the conditions described above indicate this fact with the use of a
modifier (for A/B MAC (B) processed claims) or condition code (for A/B MAC (A)
processed claims). Otherwise the claims are denied.

4. Health Department Outpatient Clinics

Services rendered free of charge by State and local health department outpatient clinics
are not covered unless the services are rendered because of the individual’s indigence or
as a means of controlling infectious diseases. Thus, services rendered by city-operated
clinics for the poor and clinics for the detection and treatment of such illnesses as
venereal disease and tuberculosis are not excluded from Medicare coverage.

5. Vocational Rehabilitation (VR) Agencies

Under the vocational rehabilitation (VR) programs of the various States, vocational
training and services, including hospital and medical care, are provided to handicapped
persons who qualify under State law. These programs are financed in part by a Federal
matching fund program set up under the Vocational Rehabilitation Act.

When items or services are furnished by a State VR agency, title XVIII benefits are
payable if the agency charges all clients for its services or makes services available
without cost only to medically indigent individuals. If a rehabilitation agency has paid for
items and services furnished by nonproviders (e.g., physicians’ services and prosthetic
appliances), it may claim the Part B payment due the beneficiary if the latter has
authorized it to do so. The procedure is similar to that provided for State welfare
agencies; the State vocational rehabilitation agency function is comparable to that of a
State welfare agency in relation to a welfare recipient.