Dealing with Complex Medicare Rules and Regulations
Part 3, Chapter 9: Medicare and Medicare Related Programs: Medicare Page 6
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Medicare may also pay for certain types of home health care, including skilled nursing services, administration of medication, management of a health care plan for a patient, and a variety of other services. To qualify for home health care you must be able to meet a number of qualifications. You must also be confined to your house. However, in terms of Medicare's definition, in some cases being confined to your house may simply mean that you are unable to leave your house without help from another person and without using a wheel chair or other assistive device, but that you do occasionally leave your house for essential appointments. (Check with Medicare to determine the rules for a specific situation.)
The enormous number of complex rules and regulations in the Medicare system creates a great deal of confusion for Medicare beneficiaries. When you finally think you've begun to understand the rules, you find that many of them have exceptions or have been changed.
For example, there are exceptions to the limiting charge rule. Ordinarily, a provider who does not accept assignment cannot charge a Medicare beneficiary more than 115% of the Medicare allowable amount. However, under current Medicare regulations, when occupational therapy is provided by an independent occupational therapist, the limiting charge may apply only to the first $900, the maximum amount that Medicare will generally consider for payment each year for such therapy. Bills above that $900 amount during the same year can reflect the occupational therapist's standard fee. In such situations, the Medicare limiting charge rule does not apply.
There are exceptions to the general rules that govern the Medicare claim-processing system, as well, particularly in terms of Explanation of Benefits Statements. For example, Medicare rules generally provide for full payment to laboratories for many standard tests. For that reason, Medicare may pay laboratories directly. However, in many cases Medicare beneficiaries report that they do not receive an EOMBS for claims for laboratory tests unless they specifically request one from Medicare.
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