Reminder: Medicare Patient Equal Care Policy is the Law

It has come to our attention that some providers are refusing to offer certain services to Medicare patients that they make available to private-pay patients and patients who have other types of insurance. It is important to realize that this is a violation of the Medicare Provider Agreement and could be used as basis for provider termination per regulations at 42 CFR 489.53(a)(2).

A provider may have restrictions on the types of services it makes available or the types of health conditions it accepts based on factors such as not having the proper certifications or equipment. However, these restrictions must be applied equally to all patients in their care or seeking treatment. Providers are not allowed to refuse a service to a Medicare patient based solely on the fact that the patient is a Medicare beneficiary or that the Medicare payment may be less than other payers. Providers are encouraged to review their provider admission and/or patient policies and practices to ensure they are consistent with this requirement.

Note that this equal care policy does not include situations where the patient does not meet medical necessity and/or technical requirements for coverage under the Medicare Program regulations or LCDs/NCDs. In these instances, the patient is not restricted from the service because they are a Medicare patient, but rather are not eligible for coverage of the service under the Medicare Program because they do not meet coverage criteria.

For additional information regarding this regulation, please refer to the CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement, Chapter 5, Section 10.2

Posted 9/9/2020