Medicare Library – CMS Manuals – Medicare Agency Resources (2024)

Table of Contents

CMS Manuals Medicare General Information, Eligibility, and Entitlement Chapter 1 - General Overview Rev. 94, 10-16-2015 Chapter 2 - Hospital Insurance & Supplementary Medical Insurance Rev. 124, 05-17-2019 Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations Rev. 129, 11-22-2019 Chapter 5 - Definitions Rev. 120, 11-02-2018 Medicare Benefit Policy Manual: Chapter 1 - Inpatient Hospital Services Covered Under Part A (Rev. 234, 03-10-2017) Chapter 2 - Inpatient Psychiatric Hospital Services (Rev. 253, 12-14-2018) Chapter 3 - Duration of Covered Inpatient Services (Rev. 261; Issued: 10-04-2019) Chapter 4 - Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation (Rev. 1, 10-01-2003) Chapter 5 - Lifetime Reserve Days (Rev. 257, 03-01-2019) Chapter 6 - Hospital Services Covered Under Part B (Rev. 267, 02-04-2020) Chapter 7 - Home Health Services (Rev. 265, 01-10-2020) Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 261; Issued: 10-04-2019) Chapter 9 - Coverage of Hospice Services Under Hospital Insurance (Rev. 246, 09-14-2018 ) Chapter 10 - Ambulance Services (Rev. 243, 04-13-2018) Chapter 11 - End Stage Renal Disease (ESRD) (Rev. 257, 03-01-2019) Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage (Rev. 255, 01-25-2019) Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (Rev. 263, 12-20-2019) Chapter 14 - Medical Devices (Rev. 198, 11- 06-2014) Chapter 15 - Covered Medical and Other Health Services (Rev. 259, 07-12-2019) Chapter 16 - General Exclusions From Coverage (Rev. 198, 11-06-2014) Medicare Managed Care Manual: Chapter 1 - General Provisions (Rev. 125, 02-10-2017) ) Chapter 2 - Medicare Advantage Enrollment and Disenrollment (Rev. 07-31-2018) Chapter 4 - Benefits and Beneficiary Protections (Rev. 121, Issued: 04-22-2016) Chapter 9 - Employer/Union Sponsored Group Health Plans (Rev. 111, 05-03-2013) Chapter 10 - MA Organization Compliance with State Law and Preemption by Federal Law (Rev. 103, 11-04-2011 ) Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements (Rev. 83, 04-25-2007) Chapter 14 - Contract Determinations and Appeals (Rev. 122, 05-27-2016) Chapter 16a - Private Fee-for-Service (PFFS) Plans (Rev. 99, Issued: 05-27-2011) Chapter 16b - Special Needs Plans (Rev. 123, Issued: 08-19-2016 ) Chapter 17 (Subchapter D) - Medicare Cost Plan Enrollment and Disenrollment Instructions (Rev. 38, 10-31-2003) Chapter 17 (Subchapter F) - Benefits and Beneficiary Protections (Rev. 77, 10-28-2005) Chapter 21 - Compliance Program Guidelines (Rev. 110, 01-11-2013) Note: this is also listed as “Chapter 9 of the Prescription Drug Benefit Manual” Medicare Prescription Drug Benefits Manual: Chapter 3 - Eligibility, Enrollment and Disenrollment (Rev. 07-31-2018) Chapter 4 - Creditable Coverage Period Determination and the Late Enrollment Penalty (In effect: 04-01-2010) Chapter 5 - Benefits and Beneficiary Protections (Rev. 14, 09-30-2011) Chapter 6 - Part D Drugs and Formulary Requirements (Rev. 18, 01-15-2016) Chapter 7 - Medication Therapy Management and Quality Improvement Program (Rev. 11, 02-19-2010) Chapter 9 - Compliance Program Guidelines (Rev. 16, 01-11-2013) Note: this is also listed as “Chapter 21 of the Managed Care Manual” Chapter 12 - Employer/Union Sponsored Group Health Plans (Rev.6, 11-07-2008) Chapter 13 - Premium and Cost-Sharing Subsidies for Low-Income Individual (Rev. 14, 10-01-2018) Chapter 14 - Coordination of Benefits (Rev. 17, 08-23-2013) Medicare Marketing Manual: Medicare Marketing Guidelines (Issued: 07/20/2017) Medicare Communications and Marketing Guidelines (MCMG) (Issued: 10/05/2018) Medicare Secondary Payer (MSP) Manual: Chapter 1 - Background and Overview (Rev. 125, 03-22-2019) Chapter 2 - MSP Provisions (Rev. 118, 04-28-2016) Chapter 3 - MSP Provider, Physician, and Other Supplier Billing Requirements (Rev. 125, 03-22-2019) Chapter 4 - Coordination of Benefits Contractor (COBC) Requirements (Rev. 125, 03-22-2019) Chapter 5 - Contractor Prepayment Processing Requirements (Rev. 125, 03-22-2019) Chapter 6 - Medicare Secondary Payer (MSP) CWF Process (Rev. 76, 11-19-2010) FAQs

CMS Manuals

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General Medicare Info
New to Medicare Info
Medicare Cost and Payment Info
Medicare Benefits
Coverage Types

Medicare General Information, Eligibility, and Entitlement

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Chapter 1 -
General Overview
Rev. 94, 10-16-2015

General Program Benefits
Administration of the Medicare Program - Introduction
Federal Government Administration of the Health Insurance Program
Role of A/B MACs (A) and (HHH)
Role of A/B MACs (B)
Background and Responsibilities of the Peer Review Organization (PROs)
Institutional Planning and Budgeting
CMS Managed Modules for Software Programs and Pricing/Coding Files

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Chapter 2 -
Hospital Insurance & Supplementary Medical Insurance
Rev. 124, 05-17-2019

Hospital Insurance Entitlement
Hospital Insurance Obtained by Premium Payment
End of Coverage for Hospital Insurance
Supplementary Medical Insurance
Identifying the patient’s health Insurance Record using the “Medicare Card”
Medicare Part C, Medicar+Choice

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Chapter 3 -
Deductibles, Coinsurance Amounts, and Payment Limitations
Rev. 129, 11-22-2019

Hospital Insurance (Part A)
Supplementary Medical Insurance (SMI) (Part B)
Outpatient Mental Health Treatment Limitation
Limitation on Physical Therapy, Occupational Therapy and Speech-Language Pathology Services

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Chapter 5 -
Definitions
Rev. 120, 11-02-2018

Provider and Related Definitions
Hospital Defined
Skilled Nursing Facility Defined
Religious Nonmedical Health Care Institution Defined
Home Health Agency Defined
Hospice
Physician Defined
Health Maintenance Organizations (HMOs) Defined
Other Definitions

Medicare Benefit Policy Manual:

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Chapter 1 -
Inpatient Hospital Services Covered Under Part A
(Rev. 234, 03-10-2017)

Covered Inpatient Hospital Services Covered Under Part A
Nursing and Other Services
Drugs and Biologicals
Supplies, Appliances, and Equipment
Other Diagnostic or Therapeutic Items or Services
Inpatient Services in Connection With Dental Services
Health Care Associated With Pregnancy
Termination of Pregnancy
Treatment for Infertility
Inpatient Rehabilitation Facility (IRF) Services
Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
Religious Nonmedical Health Care Institution (RNHCI) Services

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Chapter 2 -
Inpatient Psychiatric Hospital Services
(Rev. 253, 12-14-2018)

Inpatient Psychiatric Facility Services
Admission Requirements
Medical Records Requirements
Personnel Requirements
Psychological Services
Social Services
Therapeutic Activities
Benefit Limits in Psychiatric Hospitals
Benefits Exhaust

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Chapter 3 -
Duration of Covered Inpatient Services
(Rev. 261; Issued: 10-04-2019)

Benefit Period (Spell of Illness)
Inpatient Benefit Days
Inpatient Days counting towards Benefit Maximums

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Chapter 4 -
Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation
(Rev. 1, 10-01-2003)

Inpatient Psychiatric Benefit Days Reduction
Days of Admission, Discharge, and Leave
Reduction for Psychiatric Services in General Hospitals
Determining Days Available
Inpatient Psychiatric Hospital Services - Lifetime Limitation

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Chapter 5 -
Lifetime Reserve Days
(Rev. 257, 03-01-2019)

Summary of Provision
When Payment Will Be Made for Reserve Days
Election Not to Use Lifetime Reserve Days
Content of Election

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Chapter 6 -
Hospital Services Covered Under Part B
(Rev. 267, 02-04-2020)

Medical and Other Health Services Furnished to Inpatients of Participating Hospitals
Outpatient Hospital Services
Drugs and Biologicals
Other Covered Services and Items
Sleep Disorder Clinics
Intermittent Peritoneal Dialysis Services
Outpatient Hospital Psychiatric Services
Rental and Purchase of Durable Medical Equipment
Services of Interns And Residents

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Chapter 7 -
Home Health Services
(Rev. 265, 01-10-2020)

Home Health Prospective Payment System (HH PPS)
Conditions To Be Met for Coverage of Home Health Services
Conditions Patient Must Meet to Qualify for Coverage of Home Health Services
Covered Services Under a Qualifying Home Health Plan of Care
Coverage of Other Home Health
Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B)
Duration of Home Health Services
Specific Exclusions From Coverage as Home Health Services
Medical and Other Health Services Furnished by Home Health Agencies
Physician Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA)
Use of Telehealth in Delivery of Home Health Services

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Chapter 8 -
Coverage of Extended Care (SNF) Services Under Hospital Insurance
(Rev. 261; Issued: 10-04-2019)

Requirements – General
Prior Hospitalization and Transfer Requirements
Skilled Nursing Facility Level of Care – General
Physician Certification and Recertification f or Extended Care Services
Covered Extended Care Services
Covered Extended Care Days
Medical and Other Health Services Furnished to SNF Patients

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Chapter 9 -
Coverage of Hospice Services Under Hospital Insurance
(Rev. 246, 09-14-2018 )

Requirements – General
Certification and Election Requirements
Coinsurance
Benefit Coverage
Limitation on Liability for Certain Hospice Coverage Denials
Provision of Hospice Services to Medicare/Veteran’s Eligible Beneficiaries
Hospice Contracts with An Entity for Services not Considered Hospice Services
Hospice Pre-Election Evaluation and Counseling Services
Caps and Limitations on Hospice Payments

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Chapter 10 -
Ambulance Services
(Rev. 243, 04-13-2018)

Ambulance Service
Coverage Guidelines for Ambulance Service Claims
Implementation of the Ambulance Fee Schedule

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Chapter 11 -
End Stage Renal Disease (ESRD)
(Rev. 257, 03-01-2019)

Definitions Relating to ESRD
Renal Dialysis Items and Services
Home Dialysis
Other Services
ESRD Prospective Payment System (PPS) Base Rate
ESRD PPS Case-Mix Adjustments
ESRD PPS Transition Period
Bad Debts
Medicare as a Secondary Payer
Definitions Relating to ESRD
Renal Dialysis Items and Services
Home Dialysis
Other Services
ESRD Prospective Payment System (PPS) Base Rate
ESRD PPS Case-Mix Adjustments
ESRD PPS Transition Period80 - Bad Debts
Medicare as a Secondary Payer
Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury (AKI)
Transplantation

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Chapter 12 -
Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
(Rev. 255, 01-25-2019)

Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare
Required and Optional CORF Services
Rules for Provision of Services
Specific CORF Services

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Chapter 13 -
Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
(Rev. 263, 12-20-2019)

RHC and FQHC General Information, Location Requirements, Staffing Requirements, Visits, Services, Payment Rate, Cost Reports
Non RHC/FQHC Services
RHC and FQHC Charges, Coinsurance, Deductible, and Waivers
Commingling
Physician Services
Services and Supplies Furnished “Incident to” Physician’s Services
Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services
Services and Supplies Furnished Incident to NP, PA, and CNM Services
Clinical Psychologist and Clinical Social Worker Services
Services and Supplies Incident to CP Services
Mental Health Visits
Physical Therapy, Occupational Therapy, and Speech Language Pathology Services
Visiting Nursing Services
Telehealth Services
Hospice Services
Preventive Health Services
Care Management Services
Virtual Communication Services

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Chapter 14 -
Medical Devices
(Rev. 198, 11- 06-2014)

Coverage of Medical Devices
Food and Drug Administration (FDA)-Approved Investigational Device Exemption (IDE) Studies
Hospital Institutional Review Board (IRB) Approved Non-significant Risk Devices
Services Related to and Required as a Result of Services Which are Not Covered under Medicare

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Chapter 15 -
Covered Medical and Other Health Services
(Rev. 259, 07-12-2019)

Supplementary Medical Insurance (SMI) Provisions
When Part B Expenses Are Incurred
Physician Services
Effect of Beneficiary Agreements Not to Use Medicare Coverage
Drugs and Biologicals
Services and Supplies
Sleep Disorder Clinics
Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
X -Ray, Radium, and Radioactive Isotope Therapy
Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
Durable Medical Equipment – General
Prosthetic Devices
Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes
Therapeutic Shoes for Individuals with Diabetes
Dental Services
Clinical Psychologist Services
Clinical Social Worker (CSW) Services
Nurse-Midwife (CNM) Services
Physician Assistant (PA) Services
Nurse Practitioner (NP) Services
Clinical Nurse Specialist (CNS) Services
Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) under Medical Insurance
Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
Chiropractic Services – General
Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities
Ambulatory Surgical Center Services
Telehealth Services
Preventive and Screening Services
Foot Care
Diabetes Self-Management Training Services
Kidney Disease Patient Education Services

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Chapter 16 -
General Exclusions From Coverage
(Rev. 198, 11-06-2014)

General Exclusions from Coverage
Services Not Reasonable and Necessary
Foot Care
No Legal Obligation to Pay for or Provide Services
Items and Services Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments
Services Not Provided Within United States
Services Resulting from War
Personal Comfort Items
Routine Services and Appliances
Hearing Aids and Auditory Implants
Custodial Care
Cosmetic Surgery
Charges Imposed by Immediate Relatives of the Patient or Members of the Patient’s Household
Dental Services Exclusion
Services Reimbursable Under Automobile, No Fault, Any Liability Insurance or Workers’ Compensation
Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider
Services Related to and Required as a Result of Services Which Are Not Covered under Medicare

Medicare Managed Care Manual:

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Chapter 1 -
General Provisions
(Rev. 125, 02-10-2017) )

Legislative History
Types of Medicare Advantage (MA) Plans
Other MA Plans
Medicare Cost Plans and Health Care Prepayment Plans (HCPP)

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Chapter 2 -
Medicare Advantage Enrollment and Disenrollment
(Rev. 07-31-2018)

Definitions
Eligibility for Enrollment in MA Plans
Election Periods and Effective Dates
Enrollment Procedures
Disenrollment Procedures
Post-Enrollment Activities
Appendices & Exhibits

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Chapter 4 -
Benefits and Beneficiary Protections
(Rev. 121, Issued: 04-22-2016)

Introduction
Ambulance, Emergency, Urgently Needed and Post-Stabilization
Supplemental Benefits
Over-the-Counter (OTC) Benefits
Cost-sharing Guidance
Meaningful Difference
Non-Renewal Based on Low Enrollment
Value-Added Items and Services (VAIS)
National and Local Coverage Determinations
Rewards and Incentives
Access to and Availability of Services
Coordination of Medicare Benefits with Employer/Union Group
Medicare Secondary Payer (MSP) Procedures
Service Area
Benefits during Disasters and Catastrophic Events
Beneficiary Protections Related to Plan-Directed Care
Balance Billing
Information on Advance Directives
Part C Explanation of Benefits (EOB)
Educating and Enrolling Members in Medicaid and Medicare Savings

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Chapter 9 -
Employer/Union Sponsored Group Health Plans
(Rev. 111, 05-03-2013)

Introduction
Benefit Design Requirement Waivers
Enrollment Requirement Waivers
Service Area Requirement Waivers
Marketing Requirement Waivers
Waivers Only Applicable to Direct Contract EGWPs
Appendices

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Chapter 10 -
MA Organization Compliance with State Law and Preemption by Federal Law
(Rev. 103, 11-04-2011 )

Introduction
State Licensure Requirement
Federal Preemption of State Law
Medicare Secondary Payer (MSP) Rules
State Premium Taxes or Other Fees Imposed on Federal Payment to MA Organizations
Examples of Federal Preemption Scenario

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Chapter 11 -
Medicare Advantage Application Procedures and Contract Requirements
(Rev. 83, 04-25-2007)

Definitions
General Medicare Advantage Application and Contract Provisions
Minimum Enrollment Requirements for MA Organizations
Term and Effective Date of an MA Contract
Contracting Prohibitions Under the Medicare Advantage (MA) Program
MA Contract Renewal
Contract Nonrenewal
Contract Terminations
Modification or Termination of an MA Contract by Mutual Consent
MA Contract Provisions
MA Organization Relationship with Related Entities, Contractors, Subcontractors, First-Tier and Downstream Entities
Compliance with Other Laws and Regulations
Certification of Data That Determine Payment Requirements
Special Rules for Religious Fraternal Benefit (RFB) Societies

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Chapter 14 -
Contract Determinations and Appeals
(Rev. 122, 05-27-2016)

Contract Determinations
Hearings
Review by the CMS Administrator
Reopening of Contract Determination or Decision of a Hearing Officer or the CMS Administrator

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Chapter 16a -
Private Fee-for-Service (PFFS) Plans
(Rev. 99, Issued: 05-27-2011)

Introduction
General Requirements
Access to Services
Provider Types: Direct-Contracting, Deemed-Contracting, and Non-Contracting
PFFS Terms and Conditions of Payment for Deemed Providers
Variations in Payment Rates to Providers
PFFS Payment Rules for Providers and Cost Sharing Rules for Members
Balance Billing Rules
Prohibition on Prior Authorization, Prior Notification, and Referrals
Written Advance Organization Determinations
Prompt Payment Requirements
Timing Filing Requirement
Provider Payment Dispute Resolution Process
Requirement for PFFS Plans to Provide an Explanation of Benefits to Members
Requirement for PFFS Plans to have a Quality Improvement Program
PFFS Crosswalk Options

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Chapter 16b -
Special Needs Plans
(Rev. 123, Issued: 08-19-2016 )

Introduction
Description of SNP Types
Application, Approval, and Service Area Expansion Requirements
Enrollment Requirements
Renewal Options and Crosswalks
Marketing
Covered Benefits
Quality Improvement

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Chapter 17 (Subchapter D) -
Medicare Cost Plan Enrollment and Disenrollment Instructions
(Rev. 38, 10-31-2003)

Definitions
Eligibility for Enrollment in a Medicare Cost Plan
Enrollment Periods and Effective Date of Enrollment
Enrollment Procedures
Disenrollments
Post-Enrollment/Disenrollment Activities
Exhibits

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Chapter 17 (Subchapter F) -
Benefits and Beneficiary Protections
(Rev. 77, 10-28-2005)

General Requirements
Requirements of Specific Benefits
Hospice
Financial Responsibility
Out-of-Area, Out-of-Network and Extended Absence
Cost Employer Group Health Plans (EGHP)
Medicare Secondary Payer
National Coverage Determinations and Legislative Changes in Benefits
Discrimination Against Beneficiaries Prohibited
Disclosure Requirements
Confidentiality and Records
Availability, Accessibility, and Continuity
Information on Advance Directives

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Chapter 21 -
Compliance Program Guidelines
(Rev. 110, 01-11-2013)
Note: this is also listed as “Chapter 9 of the Prescription Drug Benefit Manual”

Introduction
Definitions
Overview of Mandatory Compliance Program
Sponsor Accountability for and Oversight of FDRs
Elements of an Effective Compliance Program
Appendices

Medicare Prescription Drug Benefits Manual:

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Chapter 3 -
Eligibility, Enrollment and Disenrollment
(Rev. 07-31-2018)

Definitions
Eligibility for Enrollment in a Part D Plan
Enrollment and Disenrollment Periods and Effective Dates
Enrollment Procedures
Disenrollment Procedures
Post-Enrollment Activities
Appendices & Exhibits

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Chapter 4 -
Creditable Coverage Period Determination and the Late Enrollment Penalty
(In effect: 04-01-2010)

Process for Making a Creditable Coverage Period Determination
Attestation of Creditable Prescription Drug Coverage
Reporting Creditable Coverage Period Determinations to CMS
CMS Calculating & Reporting LEP to Part D Sponsors
Notification to Beneficiaries of the Late Enrollment Penalty
Billing, Collecting, and Refunding the LEP
LEP Consideration Process
Information Retention Requirements
Appendices
Exhibits

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Chapter 5 -
Benefits and Beneficiary Protections
(Rev. 14, 09-30-2011)

Benefits and Beneficiary Protections
Requirements Related to Qualified Prescription Drug Coverage
Incurred/ “True Out-of-Pocket” (TrOOP) Costs
Prescription Drug Plan Service Areas
Access to Covered Part D Drugs

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Chapter 6 -
Part D Drugs and Formulary Requirements
(Rev. 18, 01-15-2016)

Definition of a Part D Drug
Part D Exclusions
Formulary Requirements
Appendices

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Chapter 7 -
Medication Therapy Management and Quality Improvement Program
(Rev. 11, 02-19-2010)

Medication Therapy Management and Quality Improvement Program
Quality Assurance Requirements
Medication Therapy Management Program (MTMP)
Consumer Satisfaction Surveys
Electronic Prescription Program (E-prescribing)
Drug Utilization Management Program
Part D Complaints Processing
Appendices

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Chapter 9 -
Compliance Program Guidelines
(Rev. 16, 01-11-2013)
Note: this is also listed as “Chapter 21 of the Managed Care Manual”

Introduction
Definitions
Overview of Mandatory Compliance Program
Sponsor Accountability for and Oversight of FDRs
Elements of an Effective Compliance Program
Appendices

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Chapter 12 -
Employer/Union Sponsored Group Health Plans
(Rev.6, 11-07-2008)

Introduction
Approved Employer/Union Sponsored Group Health Plan Waivers
Appendices

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Chapter 13 -
Premium and Cost-Sharing Subsidies for Low-Income Individual
(Rev. 14, 10-01-2018)

Introduction
Definitions
Eligibility Requirements
Eligibility Determinations
Premium Subsidy
Cost-Sharing Subsidy
Part D Sponsor Responsibilities When Administrating the Low – In-come Subsidy
Application of Low-Income Subsidy to Employer Group Waivers Plans
Enhanced Allotment for Low-Income Residents of the Territories
Appendices

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Chapter 14 -
Coordination of Benefits
(Rev. 17, 08-23-2013)

Introduction
Overview
CMS Requirements
Beneficiary Requirements
Part D Sponsor Requirements
Coordination of Benefit Activities of Non-Part D Payers
Appendices

Medicare Marketing Manual:

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Medicare Marketing Guidelines
(Issued: 07/20/2017)

Introduction
Materials Not Subject To Marketing Review
Plan/Part D Sponsor Responsibilities
General Marketing Requirements
Disclaimer Requirements
Required Documents
Outreach, Marketing and Educational Events, and Sales Activities
Telephonic Activities and Scripts
The Marketing Review Process
Part D Sponsor Websites and Social/Electronic Media
Promotional Activities, Rewards, and Incentives
Marketing and Sales Oversight and Responsibilities
Employer/Union Health Plans
Use of Medicare Mark for Part D Sponsors
Allowable Use of Medicare Beneficiary Information Obtained from CMS
Appendices

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Medicare Communications and Marketing Guidelines (MCMG)
(Issued: 10/05/2018)

Introduction
Communications and Marketing Definitions
General Communication Requirements
General Marketing Requirements
Outreach Activities
Activities in Healthcare Settings
Websites and Social/Electronic Media
Call Centers
Tracking, Submission, and Review Process
Required Materials
Agent/Broker Activities, Oversight, and Compensation Requirements
Use of Medicare Beneficiary Information obtained from CMS
Appendices

Medicare Secondary Payer (MSP) Manual:

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Chapter 1 -
Background and Overview
(Rev. 125, 03-22-2019)

General Provisions
Definitions
Beneficiary’s Rights and Responsibility
Effect of GHP’s Payments on Deductible, Coinsurance and Utilization
Rules Defining Employees Covered by GHP’s and LGHP’s
Aggregation Rules Applicable to Determine the Employer Size
Prohibitions Applicable to Employers offering GHP Coverage
Actions Resulting from GHP or LGHP Nonperformance
Referral to the Regional Office
Federal Government’s Right to Sue and Collect Double

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Chapter 2 -
MSP Provisions
(Rev. 118, 04-28-2016)

Medicare Secondary Payer Provisions for Working Aged Individuals
Medicare Secondary Payer Provisions for End-Stage Renal Disease (ESRD) Beneficiaries
Medicare Secondary Payer Provision for Disabled Beneficiaries
Liability Insurance
Workers' Compensation (WC)
No-Fault Insurance
Interest on MSP Recovery Claims

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Chapter 3 -
MSP Provider, Physician, and Other Supplier Billing Requirements
(Rev. 125, 03-22-2019)

General
Obtain Information From Patient or Representative at Admission or Start of Care
Provider, Physician, and Other Supplier Billing
Completing the Form CMS-1450 in MSP Situations by Providers of Service

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Chapter 4 -
Coordination of Benefits Contractor (COBC) Requirements
(Rev. 125, 03-22-2019)

Overview and General Responsibilities
CMS IEQ Responsibilities
IRS/SSA/CMS Data Match
The Coordination of Benefits Contractor (COBC) Discontinues Dissemination of the Right of Recovery Letters
Exception for Small Employers in Multi-Employer Group Health Plans (GHPs)

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Chapter 5 -
Contractor Prepayment Processing Requirements
(Rev. 125, 03-22-2019)

Coordination with the Benefits Coordination & Recovery Center (BCRC)
Sources That May Identify Other Insurance Coverage
Develop Claims for Medicare Secondary Benefits
FI and Carrier Claim Processing Rules
MSP Pay Modules to Calculate Medicare Secondary Payment Amount
MSP Reports
Hospital Review Protocol for Medicare Secondary Payer

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Chapter 6 -
Medicare Secondary Payer (MSP) CWF Process
(Rev. 76, 11-19-2010)

General Information
MSP Maintenance Transaction Record Processing
CWF, MSP Auxiliary File30.1 -Integrity of MSP Data
MSP Claim Processing
Special CWF Processes
Use of Inter-Contractor Notices (ICNs) and CWF for Development Conditional Payment Amount
Converting Health Insurance Portability and Accountability Act (HIPAA) Individual Relationship Codes to Common Working File (CWF) Medicare Secondary Payer(MSP) Patient Relationship Codes

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Is CMS Medicare same as Medicare? ›

Is CMS the Same as Medicare? No. The Centers for Medicare & Medicaid Services (CMS) is part of the U.S. Department of Health and Human Services (HHS) and is not the same as Medicare. Medicare is a federally run government health insurance program, which is administered by CMS.

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What does the Medicare internet only manual contain? ›

The Internet-only Manuals (IOMs) are a replica of the Agency's official record copy. They are CMS' program issuances, day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives.

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What are the new CMS rules for 2024? ›

Beginning January 1, 2024, CMS is finalizing implementation of a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211. This add-on code will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.

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Where can I get questions answered for Medicare? ›

Call us at 1-800-MEDICARE (1-800-633-4227). Help from Medicare is available 24 hours a day, 7 days a week, except some federal holidays. TTY users can call 1-877-486-2048.

What are the three components of CMS? ›

A content management system (CMS) usually has three main parts: a database, a workflow scheme, and an interface that has editing tools and output utilities.

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What are the key functions of CMS? ›

The key functions of most CMS applications include:

storing.
indexing.
search and retrieval.
format management.
revision control.
access control.
publishing.
reporting.

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Are CMS guidelines binding? ›

CMS Rulings are binding on all CMS components, Medicare contractors, the Provider Reimbursem*nt Review Board, the Medicare Geographic Classification Review Board, and Administrative Law Judges (ALJs) of the Social Security Administration (SSA) who hear Medicare appeals.

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How do you qualify for $144 back from Medicare? ›

To qualify for the giveback, you must:

Be enrolled in Medicare Parts A and B.
Pay your own premiums (if a state or local program is covering your premiums, you're not eligible).
Live in a service area of a plan that offers a Part B giveback.

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Why are people leaving Medicare Advantage plans? ›

Most individuals that dislike a Medicare Advantage plan usually have had a bad experience with in-network providers, plan authorizations for medical care, or having to wait a long time to have an appointment scheduled. Some of these concerns can be attributed to the healthcare provider.

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What did seniors do before Medicare? ›

Prior to Medicare, only a little over one-half of those aged 65 and over had some type of hospital insurance; few among the insured group had insurance covering any part of their surgical and out-of-hospital physicians' costs.

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What are 5 items or services not covered by Medicare? ›

Some of the items and services Medicare doesn't cover include:

Long-term care (also called. custodial care. Custodial care. ...
Most dental care.
Eye exams (for prescription glasses)
Dentures.
Most cosmetic surgery.
Massage therapy.
Routine physical exams.
Hearing aids and exams for fitting them.

More items...

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Who is the largest third party payer in the nation? ›

Types of Third-Party Payers

Currently, the largest health payer is United Health Group, which provides networks for care and is a commercial and employer-based insurance company.

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How do I get Medicare without a computer? ›

Call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. Contact your local Social Security office.

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How do I get my Medicare statement? ›

Medicare only mails MSNs every three months, but you can view your MSNs 24 hours a day by visiting MyMedicare.gov. Registering for access to Medicare's free, secure online service allows you to review all bills processed within the past 36 months.

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Is Medicare sending out new cards for 2024? ›

contact your plan directly to learn about your 2024 costs. Do you know what isn't new this year? Your Medicare card. Medicare beneficiaries are not receiving new cards this year, but scammers may try to convince you otherwise.

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Is there a penalty for not enrolling in Medicare Part A at age 65? ›

Part A late enrollment penalty

If you have to buy Part A, and you don't buy it when you're first eligible for Medicare, your monthly premium may go up 10%. You'll have to pay the penalty for twice the number of years you didn't sign up.

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What happens to my younger wife when I go on Medicare? ›

If you are enrolling in Medicare coverage and your spouse is younger than 65 and does not meet one of the Medicare eligibility exceptions (such as a disability or chronic condition), they will need to secure their own insurance coverage until they reach the age requirement for Medicare.

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