TN 13 (11-22)

HI 00620.050 Items and Services which a Provider, Physician or Supplier is Obligated to Furnish at Public Expense Pursuant to an Authorization Issued by a Federal Agency

Medicare payment may not be made for any item or service rendered by a provider pursuant to an authorization issued by a Federal agency, under which the Federal government agrees to pay for the services.

The VA may authorize non-Federal providers to render services at Federal expense. The VA may pay for treatment of veterans in non-VA hospitals for service-connected disabilities and, in certain circumstances, for non-service-connected disabilities, provided the VA has given prior authorization for the services. The VA may also agree to pay for emergency services furnished a veteran who appears at a hospital without prior authorization, provided a notification of the veteran's admission and a request for authorization to provide care at VA expense is submitted to the VA within 72 hours after the admission.

The VA may authorize up to 6 months of care in non-VA skilled nursing facilities (SNFs) for veterans requiring such care after transfer from a VA hospital. Services furnished pursuant to a VA authorization are not covered by Medicare and do not count against the 150 days of extended care benefits available in a year. Where a veteran remains in an SNF unit until the veteran'sVA benefits are exhausted, extended care benefits could begin under Medicare. Such benefits would begin with the first day after the VA benefits were exhausted, provided a physician certifies that the individual still requires skilled nursing care on a daily basis.

Generally, an authorization issued by the VA binds the VA to pay in full for the items and services provided. No payment may be made under Medicare for such authorized services. However, the charges for such services are credited to the Medicare deductibles. Where an authorization from the VA was not given to the party rendering the services, Medicare payment is not precluded even though the individual might have been entitled to have payment made by the VA had the individual requested the authorization. Also, Medicare secondary benefits may be payable where the VA authorizes fewer days than the total number of covered days in the stay.

Generally, it is advantageous for Medicare beneficiaries who are veterans to have items and services paid for by the VA where possible, since in most cases the VA has no deductible or coinsurance requirements. Also, services paid for in full by the VA do not count against the individual's maximum number of benefit days.

The Division of Indian Health of the United States Public Health Service authorizes private physicians and privately owned hospitals and nursing homes to provide treatment to Indians and their dependents under contractual arrangments with the Division of Indian Health. In the case of such contract health services to Indians and their dependents entitled under the Indian Health Service (IHS) program and Medicare, Medicare is the primary payer and the IHS the secondary payer.