Medicare Benefit Policy Manual

There’s a lot to know about Medicare, and that need for knowledge isn’t limited to beneficiaries. Health care providers, contractors, private insurance companies and state survey agencies are also in need-to-know positions. 

The Medicare Benefit Policy Manual has many of the Medicare answers that most people may be looking for. 

This official government document, also identified as CMS Publication 100-02, is an online reference detailing specific rules and regulations governing the Medicare program. The manual is published by the Centers for Medicare & Medicaid Services (CMS), which is the federal government body that administers Medicare. 

What Is the Medicare Benefit Policy Manual Used For?

While the Medicare Benefit Policy Manual has some use to Medicare beneficiaries and to general members of the public, the document is most often primarily used by health care professionals.

The manual includes information related to day-to-day Medicare operating instructions, policies and procedures, government statutes, regulations, guidelines and directives that all combine to shape how Medicare coverage is administered to millions of Americans. 

What Does the Medicare Benefit Policy Manual Include?

The Medicare Benefit Policy Manual covers program guidelines for hospitals, doctor’s offices, rehabilitation clinics, skilled nursing facilities, home health care companies and other health care providers who treat Medicare patients and accept Medicare coverage.

The manual also includes information for private insurance companies who sell Medicare Advantage (Medicare Part C) plans, Medicare Part D prescription drug plans and Medicare Supplement Insurance (Medigap) plans related to how Medicare plan benefits may and may not be covered, packaged, marketed, sold and administered. 

The manual mostly focuses on Medicare Part A, which covers hospital benefits and other inpatient care. There is also information about more specific topics like end-stage renal disease, opioid treatment programs, medical equipment and devices and coverage exclusions and exceptions. 

There are 17 chapters in the manual:

1. Inpatient Hospital Services Covered Under Part A
2. Inpatient Psychiatric Hospital Services
3. Duration of Covered Inpatient Services
4. Inpatient Psychiatric Benefit Days Reduction and Lifetime Limitation
5. Lifetime Reserve Days
6. Hospital Services Covered Under Part B
7. Home Health Services
8. Coverage of Extended Care (SNF) Services Under Hospital Insurance
9. Coverage of Hospice Services Under Hospital Insurance
10. Ambulance Services
11. End-Stage Renal Disease (ESRD)
12. Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
13. Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
14. Medical Devices
15. Covered Medical and Other Health Services
16. General Exclusions from Coverage
17. Opioid Treatment Programs (OTPs)

Where Can I Access the Medicare Benefit Policy Manual?

The Medicare Benefit Policy Manual is available online for free on CMS.gov, the official government website for the Centers for Medicare & Medicaid Services. There is no need to download anything. You can simply click on the chapter you wish to view. 

Each chapter is available as a separate PDF, which makes it easier to skip directly to the information you are seeking. Keep in mind that some of the chapters are very long. For example, chapter 7 (Home Health Services) contains 106 pages. However, there is a table of contents at the beginning of the chapter that can help you find the correct page for your specific need. 

If you are a current or future Medicare beneficiary, the manual that may be more helpful to you is the Medicare & You handbook, which is published every year and distributed to Medicare beneficiaries. This handbook contains information related to the patient side of Medicare and is a helpful resource for anyone who is on Medicare or will be soon.