Page 7 - Medicare Benefit Policy Manual
P. 7
A legal obligation to pay exists where a religious order either pays for or furnishes
services to members of the order. Although medical services furnished in such a setting
would not ordinarily be expressed in terms of a legal obligation, the order has an
obligation to care for its members who have rendered life-long services, similar to that
existing under an employer’s prepayment plan. Thus, payment may be made for such
services whether they are furnished by the order itself or by independent sources that
customarily charge for their services.
40.6 - Ambulance Services
(Rev. 1, 10-01-03)
B3-2306
There are numerous methods of financing ambulance companies. For example, some
volunteer organizations do not charge the patient or any other person but ask the recipient
of services for a donation to help offset the cost of the service. Although the recipients
may be under considerable moral and social pressure to donate, they are not required to
do so, and there is no enforceable legal obligation on the part of the individual or anyone
else to pay for the services. Thus, Medicare benefits would not be payable. However,
services of volunteer ambulance corps are not categorically excluded. Many such
companies regularly charge for their services and Medicare covers these services.
Some ambulance companies provide services without charge to residents of specific
geographical areas but charge non-residents to the extent they are able to pay (e.g.,
through private health insurance). Under those circumstances, the free services provided
the residents would be excluded from coverage, while the services furnished non-
residents would be covered.
Ambulance companies which charge membership fees generally do not charge additional
fees for services covered under the membership plan, although they may charge for
certain other services (e.g., additional trips or mileage). Services furnished by such
ambulance companies including services for which prepayment is made under the
membership plan, are considered to be services for which there is a legal obligation to
pay. Therefore, such services are reimbursable provided the ambulance company bills all
third party payers. Membership fees and insurance premiums are not incurred expenses
under Medicare (see the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical
and Other Health Services,” §10) and are not reimbursable.
50 - Items and Services Furnished, Paid for or Authorized by
Governmental Entities - Federal, State, or Local Governments
(Rev. 1, 10-01-03)
A3-3153, HO-260.3, B3-2309
The law contains three separate exclusions applicable to items and services furnished,
paid for or authorized by governmental entities. In general, payment may not be made
for items and services: