Services Provided to Relatives
Medicare regulations do not provide payment under Part A or Part B of Medicare for expenses that constitute charges by immediate relatives of the beneficiary or by members of his/her household. The intent of this exclusion is to bar Medicare payment for items and services furnished by physicians or suppliers who would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by a related physician or supplier, even if the bill or claim is submitted by an unrelated individual or by a partnership or professional corporation. It applies to items and services furnished incident to a physician's professional services (e.g., by the physician's nurse or technician) only if the physician who ordered or supervised the services has an excluded relationship to the beneficiary.
The following degrees of relationship are included within the definition of immediate relative:
- husband and wife
- natural or adoptive parent, child and sibling
- stepparent, stepchild, stepbrother and stepsister
- father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law and sister-in-law
- grandparent and grandchild
- spouse of grandparent or grandchild
A brother-in-law or sister-in-law relationship does not exist between a physician (or supplier) and his/her spouse's brother-in-law or sister-in law.
A father-in-law or mother-in-law relationship does not exist between a physician and his/her spouse's stepfather or stepmother.
A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or through the death of one of the parties.
For example, if a physician treats his stepfather after the death of his natural mother the service is considered furnished to an immediate relative and is excluded from coverage. Another example is if a physician treats his stepfather after the stepfather and natural mother are divorced, the service is considered furnished to an immediate relative and is excluded from coverage. Finally, if a physician treats his father-in-law after the death of his wife, the service is considered furnished to an immediate relative and is excluded from coverage.
Members of Patient's Household
Also excluded are people sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage, or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.
Charges for Physician and Physician-Related Services
This exclusion applies if the physician has an excluded relationship to the beneficiary. It includes services that are furnished, ordered, supervised or services that are incident to his/her services (e.g., by the physician's nurse or technician). It also includes services of a physician who belongs to a professional corporation.
The term "professional corporation" means a corporation that is completely owned by one or more physicians or is owned by other health care professionals as authorized by State law. It is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry or chiropractic. Any physician or group of physicians that is incorporated constitutes a professional corporation. (Generally, physicians who are incorporated identify themselves by adding letters such as P.C. or P.A. after their title.)
Charges for Items Furnished by Non-Physician Suppliers
This exclusion applies to charges imposed by a non-physician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who is related to the patient or by a partnership in which even one of the partners is related to the patient. The exclusion does not apply to charges imposed by a corporation (other than a professional corporation), regardless of the patient's relationship to any of the stockholders, officers or directors of the corporation or to the person who furnished the service.
Last Updated Aug 14, 2018