Exclusions from Medicare coverage

What this document is

42 U.S.C. s. 1395y: Exclusions from Medicare coverage is a state statute published by U.S. Government Publishing Office (govinfo.gov). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• 42 U.S.C. § 1395y(a)(9) (Custodial care exclusion)

  “(8) where such expenses are for orthopedic shoes or other supportive devices for the feet, other than shoes furnished pursuant to section 1395x(s)(12) of this title; (9) where such expenses are for custodial care (except, in the case of hospice care, as is otherwise permitted under paragraph...”

• 42 U.S.C. § 1395y(b)(3)(C) (Prohibition of financial incentives not to enroll)

  “(C) Prohibition of financial incentives not to enroll in a group health plan or a large group health plan It is unlawful for an employer or other entity to offer any financial or other incentive for an individual entitled to benefits under this subchapter not to enroll (or to terminate enrollment)...”

• 42 U.S.C. § 1395y, subsection (a)(12) (Dental Services)

  “(12) where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such...”

• 42 U.S.C. § 1395y: subsection (a)(7) (Routine Vision and Hearing Items)

  “(7) where such expenses are for routine physical checkups, eyeglasses (other than eyewear described in section 1395x(s)(8) of this title) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine...”

• 42 U.S.C. § 1395y(b)(2)(A)-(B)(ii), primary plans and repayment of conditional payments

  “Payment under this subchapter may not be made, except as provided in subparagraph (B), with respect to any item or service to the extent that - (i) payment has been made, or can reasonably be expected to be made, with respect to the item or service as required under paragraph (1), or (ii) payment...”

• 42 U.S.C. § 1395y(a)(10), exclusion of cosmetic surgery expenses and its exceptions

  “(10) where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member;”

• 42 U.S.C. § 1395y(b)(2)(A), definition of primary plan

  “the term "primary plan" means a group health plan or large group health plan, to the extent that clause (i) applies, and a workmen's compensation law or plan, an automobile or liability insurance policy or plan (including a self-insured plan) or no fault insurance, to the extent that clause (ii) applies.”

Practice this material

Questions about this source

More Federal sources sources

• Coverage for Pre-existing Conditions (Affordable Care Act) - HealthCare.govFederal guidance
• 20 C.F.R. § 404.1520 -- Evaluation of Disability in General (the five-step sequential evaluation process)Regulation
• Parts of Medicare (Medicare & You / medicare.gov)Federal guidance
• Continuation of Health Coverage (COBRA) - U.S. Department of LaborReference
• Portability of Health Coverage (HIPAA) - U.S. Department of LaborReference
• Fair Credit Reporting Act - 15 U.S.C. § 1681a (Definitions)State statute
• 15 U.S.C. s. 1681b: FCRA permissible purposes of consumer reportsState statute
• 15 U.S.C. s. 1681c: FCRA requirements relating to obsolete information in consumer reportsState statute