- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 2: Medicare Basics
Medicare Program Exclusions
No payment can be made under Medicare Part A or Medicare Part B for certain items and services. The list below includes the general Medicare program exclusions. For details regarding each exclusion, refer to the CMS IOM Publication 100-02, Medicare Benefit Policy Manual and the appropriate chapter and section as indicated.
- Charges by immediate relative or members of household (Chapter 16, Section 130)
- Cosmetic surgery (Chapter 16, Section 120)
- Conditions resulting from war (Chapter 16, Section 70)
- Custodial care (Chapter 16, Section 110)
- Dental services (Chapter 16, Section 140): care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth
- Excluded investigational devices (Chapter 14, Section 30)
- Foot care (Chapter 16, Section 30 and Chapter 15, Section 290): supportive devices for feet; routine removal of corns/calluses or trimming of nails
- Hearing aids (Chapter 16, Section 100)
- No legal obligation to pay for or provide services (Chapter 16, Section 40): members of religious orders
- Non-physician services provided to a hospital inpatient which were not provided directly or arranged for by the hospital (Chapter 16, Section 170)
- Personal comfort items and services (Chapter 16, Section 80)
- Routine services and appliances (Chapter 16, Section 90): yearly checkups; eyeglasses and contact lenses
- Services not reasonable and necessary (Chapter 16, Section 20): devices not approved by the FDA
- Services or items not provided within the United States (Chapter 16, Section 60)
- Services or items paid or expected to be paid under workers’ compensation (Chapter 16, Section 150)
- Services or items paid for by another government entity (Chapter 16, Section 50): prisoners, active duty members of the uniformed services; government research grants
- Services related to and required as a result of services which are not covered under Medicare (Chapter 16, Section 180)
Revised 1/2021