There is no need to download anything. You can simply click on the chapter you wish to view. Each chapter is available as a separate PDF, which makes it easier to skip directly to the information you are seeking. Keep in mind that some of the chapters are very long. For example, chapter 7 Home Health Services contains pages. However, there is a table of contents at the beginning of the chapter that can help you find the correct page for your specific need.
This handbook contains information related to the patient side of Medicare and is a helpful resource for anyone who is on Medicare or will be soon. Skip to search Skip to main content. Medicare Benefit Policy Manual September 22, The Medicare Benefit Policy Manual contains a vast amount of detailed information about how Medicare benefits are administered.
An MA organization must provide members in its plan with coverage of the basic benefits by furnishing the benefits directly or through arrangements, or by paying for the benefits. In addition, the law permits MA organizations to offer plans that do not require members to receive services through a provider network i.
MA coordinated care plans include a network of providers that are under contract or arrangement with the organization to deliver the benefit package approved by CMS. The network must be approved by CMS to ensure that all applicable requirements are met including access and availability standards, service area requirements, and quality standards. MA coordinated care plans include, but are not limited to, HMO plans with or without point of service options, plans offered by provider sponsored organizations, preferred provider organizations, as well as the Religious Fraternal Benefits Society plan.
An HMO is a public or private organization which provides either directly or through arrangements with others comprehensive health services to enrolled members who live within a specific geographic area. The beneficiaries pay a predetermined premium which covers the medical expenses without regard to the frequency or extent of covered services furnished. An HMO with a point-of-service plan is a plan in which a member may be reimbursed by the HMO for services received through non-network providers when network providers could have been used.
A point of service POS plan is a benefit option that an MA plan can offer to its Medicare members as an additional, mandatory supplemental, or optional supplemental benefit. In return for this flexibility, members typically have higher cost-sharing requirements for services received and, where offered as a mandatory or optional supplemental benefit, may also be charged a premium for the POS benefit option. A provider-sponsored organization is operated by providers, in which the substantial proportion of services are delivered through the sponsoring provider or affiliated providers.
Religious and Fraternal RFB Society Plans are offered by a religious and fraternal society for members of the society. Only members of the society may enroll. The society must meet Internal Revenue Service and Medicare requirements for this type of organization. A Medical Savings Account MSA is a type of MA plan that combines a high-deductible health plan and a tax advantaged personal savings account set up to fund medical costs not covered by the plan.
MSA plan members will receive an annual deposit into an interest-bearing account from CMS to help them cover their health care costs. Members will use the money in their MSAs to pay for their health care before the high deductible is reached. Once the deductible is met, the MA organization offering the MSA plan will be responsible for payment of percent of the expenses related to covered services.
For example, Chapter 7 is specific to home health services covered under Medicare Part A. If a home health care agency provides services under Part B, they should refer to chapter 15, which governs all outpatient therapy services.
Click here for a full list of all the chapters. For a list of all CMS internet-only manuals, including National Coverage Determinations and the claims processing manual, click here. This comprehensive guide to coverage, benefits and enrollment is updated annually and highlights new policy changes at the beginning of the document.
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