Audience:

DO/BO/TSC:
CR, CR TII, DRT, FR, OA, OS, RR, SR
OCO-OIO:
CA, CATA, EIE, FCR
PSC:
CRTA, CS, IES, RECONR

HI 00610.001 Scope of Benefits(SMI)

Medical insurance (Part B) covers the following types of services when a medical necessity exists.

A. Physicians' services

Physicians' services are those professional services performed by a physician for a patient including diagnosis, therapy, surgery and consultation. The term “physician” includes a doctor of medicine or osteopathy legally authorized to practice by a State. It also includes certain services performed by a doctor of dentistry, doctor of podiatric medicine, and chiropractor; and a doctor of optometry with respect to establishing the necessity for prosthetic lenses. The term “physician” does not include such practitioners as Christian Science Practitioners or naturopaths.

B. Outpatient hospital services

Hospital services provided to outpatients are covered under Part B.

C. Home health services

These are the same types of home health services as are provided under Hospital Insurance except that there is no prior hospitalization requirement. There is a 100 visit limit on Part B home health services in each calendar year.

Effective 7-1-81, the prior hospitalization requirement under Hospital Insurance and the 100 visit limitation under both Hospital and Supplementary Medical Insurance are eliminated.

D. Other services and supplies

These include a number of different medical services and supplies which may be necessary in the treatment and diagnosis of an illness or injury. They may be furnished as part of a doctor's treatment, or by a provider, an independent laboratory, the outpatient department of a hospital, by a medical clinic, or by an ambulatory surgical center. They include services and supplies (e.g., drugs and biologicals which cannot be self-administered) furnished as an incident to a physicians' professional service, of kinds which are commonly furnished in physicians' offices either without charge or the charge for which is usually included in the physicians' bills.

They also include diagnostic tests, such as X-rays and laboratory tests; radiation therapy; portable diagnostic X-ray services furnished in the patient's home; surgical dressings, and splints, casts, and similar devices; rental or purchase of durable medical equipment, such as a wheelchair, hospital bed, or oxygen equipment prescribed by a doctor to be used in the patient's home; prosthetic devices (other than dental) to replace all or part of an internal body organ (including contiguous tissue) or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ such as cardiac pacemakers and replacements or repairs of such devices; and ambulance services.

Part B also covers outpatient physical therapy and speech pathology services when such services are furnished by or under arrangements made by participating providers of services.

In general, medical insurance benefits are 80 percent of reasonable charges for covered services after an annual deductible has been met. There is also a Part B blood deductible equal to the charge of the first three pints of blood furnished in a calendar year. Expenses incurred for this blood deductible do not count as incurred expenses toward the annual cash deductible and are not creditable to the Part A blood deductible.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600610001
HI 00610.001 - Scope of Benefits(SMI) - 05/09/2014
Batch run: 05/09/2014
Rev:05/09/2014