Supplementary Medical Insurance (SMI) Provisions

10 - Supplementary Medical Insurance (SMI) Provisions (Rev. 11355; Issued:04-14-22; Effective: 05-16-22; Implementation: 05-16-22) The supplementary medical insurance plan covers expenses incurred for the following medical and other health services under Part B of Medicare: • Physician’s services, including surgery, consultation, office and institutional calls, and services and supplies furnished incident to a physician’s professional service; • Outpatient hospital services furnished incident to physicians services; • Outpatient diagnostic services furnished by a hospital; • Outpatient physical therapy, outpatient occupational therapy, outpatient speech-language pathology services; • Diagnostic x-ray tests, laboratory tests, and other diagnostic tests; • X-ray, radium, and radioactive isotope therapy; • Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations; • Rental or purchase of durable medical equipment for use in the patient’s home; • Ambulance service; • Prosthetic devices, other than dental, which replace all or part of an internal body organ; • Leg, arm, back and neck braces and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or change in the patient’s physical condition; • Certain medical supplies used in connection with home dialysis delivery systems; • Rural health clinic (RHC) services; • Federally Qualified Health Center (FQHC) services; • Ambulatory surgical center (ASC) services; • Screening mammography services; • Screening pap smears and pelvic exams; • Screening glaucoma services; • Influenza, pneumococcal pneumonia, hepatitis B, and COVID-19 vaccines; • Colorectal screening; • Bone mass measurements; • Diabetes self-management services; • Prostate screening; and • Home health visits after all covered Part A visits have been used. See §250 for provisions regarding supplementary medical insurance coverage of certain of these services when furnished to hospital and SNF inpatients. Payment may not be made under Part B for services furnished an individual if the individual is entitled to have payment made for those services under Part A. An individual is considered entitled to have payment made under Part A if the expenses incurred were used to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of a request for payment or lack of a physician certification. Some medical services may be considered for coverage under more than one of the above-enumerated categories. For example, electrocardiograms (EKGs) can be covered as physician’s services or as other diagnostic tests. It is sufficient to determine that the requirements for coverage under one category are met to permit payment. Membership dues, subscription fees, charges for service policies, insurance premiums, and other payments analogous to premiums which entitle enrollees to services or to repairs or replacement of devices or equipment or parts thereof without charge or at a reduced charge, are not considered expenses incurred for covered items or services furnished under such contracts or undertakings. Examples of such arrangements are memberships in ambulance companies, insurance for replacement of prosthetic lenses, and service contracts for durable medical equipment.