Services Not Provided Within United States

60 - Services Not Provided Within United States (Rev. 102; Issued: 02-13-09; Effective/Implementation Date: 03-13-09) Items and services furnished outside the United States are excluded from coverage except for the following services, and certain services rendered on board a ship: • Emergency inpatient hospital services where the emergency occurred: o While the beneficiary was physically present in the United States; or o In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State. See Pub. 100-04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures. • Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United States, if the hospital was closer to, or substantially more accessible from, the beneficiary’s United States residence than the nearest participating United States hospital which was adequately equipped to deal with and available to provide treatment of the illness or injury (see Pub. 100-04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures); • Physician and ambulance services furnished in connection with a covered foreign hospitalization. Program payment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.1 for a description of claims processing procedures); • Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States territorial waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.7 for a description of claims processing procedures); and The term “United States” means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States. A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government. Payment may not be made for any item provided or delivered to the beneficiary outside the United States, even though the beneficiary may have contracted to purchase the item while they were within the United States or purchased the item from an American firm. Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India. Under the Railroad Retirement Act, payment is made to Qualified Railroad Retirement beneficiaries (QRRBs) by the RRB for covered hospital services furnished in Canadian hospitals as well as in the U.S. Physician and ambulance services are not covered by the Railroad Retirement Act; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, RRB processes the Part B claim. In such cases the RRB determines: • Whether the requirements are met for the inpatient services; and • Whether the physician and/or ambulance services were furnished in connection with the services. Services for an individual who has elected religious nonmedical health care status may be covered if the above requirements are met but this revokes the religious nonmedical health care institution election.