The Five Parts That Decide What Medicare Pays

Somewhere in a book of five volumes sits the sentence that decided your claim. The book is Title 42 of the Code of Federal Regulations (CFR), the shelf where federal rules are kept. Five of its parts are the place to start on a Medicare payment question. Learn those five numbers and you know which drawer to open first.

A woman opens a hospital bill for care she believed was covered. An adviser at a benefits desk answers the same question for the fourth time this month. A son three states away tries to work out which of five volumes holds the sentence that decided it. All three want something better than call the number on the back, and all three need the same five numbers.

Which five parts decide what Medicare pays?#

Parts 405, 409, 410, 422 and 424. Five numbers, and they are the working set here. All of them sit in Title 42, chapter four. That chapter belongs to the agency that runs Medicare, which is why its rules cluster in one place rather than spreading across the book.

The wider shape of the rulebook explains why a chapter carries an agency name. What matters here is narrower. These five rooms are where to start looking.

Nobody picked these five as a teaching set. The law wired them together.

Look at 424. It is the rule that lets money move at all, and inside its own text it points at 409 and 410 by number, as where covered services are specified. Read that twice. The map is drawn inside the law, not by somebody explaining it afterwards.

Think of the book as a filing cabinet with drawers labelled by subject rather than by date. Neighbours matter. Open the drawer you need and the other four are within arm’s reach.

What does part 405 actually govern?#

Mostly procedure. The official heading reads Federal Health Insurance for the Aged and Disabled, which sounds like the whole programme and is not. It holds some odds and ends too, such as private contracts and rural health clinic services, but the part a claimant meets is the machinery. How a claim is decided. How a decision is reviewed. What happens on the day you disagree.

405 is the part you open after a decision already went against you. The letter arrives, the answer is no, and the rules for what comes next are here.

Keep it apart from the coverage question in your head. This part tells you how your paper is handled. It does not tell you whether the thing you wanted was ever payable.

You can follow the procedure perfectly on a claim that was never payable. The rules that decide payable live somewhere else.

Where do the hospital rules live?#

In 409, under the heading Hospital Insurance Benefits. Inpatient stays. Skilled nursing care that follows a hospital stay. Home health on the hospital side. Deductible and coinsurance rules sit here too, with the lifetime reserve days that decide what happens when a stay runs longer than the benefit period allows.

Hospice is the trap, and 409 tells you so itself. It says hospital insurance pays for hospice care, then sends the reader to part 418 for the rules. The money is Part A. The rulebook is one shelf over. That split is the whole reason to learn part numbers instead of programme names.

Families arguing about skilled nursing care after a hospital stay are arguing about something written on these pages. Nobody in the room has said the number out loud.

Definitions come third in the part, right after its statutory basis and scope, which is worth knowing before you go looking. Regulations define their terms near the start. Then they mean those definitions throughout, unless the context says otherwise.

A word in a rulebook is not the word you use at the kitchen table. Hospital and covered both mean something narrower here than in normal speech. The narrow meaning decides the money.

Where do the doctor and outpatient rules live?#

In 410, under the heading Supplementary Medical Insurance (SMI) Benefits. Doctor visits, outpatient care, lab work, most equipment used at home, and preventive services. This is where your day to day questions land, the ones that begin without any hospital admission.

Someone asking whether a scan, a wheelchair or a yearly check is covered is asking a 410 question. The letter in your hand is not required to name it.

Hold the pairing. One part is the hospital side. The other is everything else on the medical side, and between them they cover nearly all of it.

Even 424 treats them as a pair, naming both in the same breath when it defines a covered service. Two rooms, one job between them.

What changes inside a Medicare Advantage plan?#

A private company steps between you and the programme, and 422 governs that company. Coverage is still measured against the same rules underneath. What changes is who decides first, how fast the clock runs, what the plan must put on paper, and how you push back when the answer is no.

So an Advantage member may need two parts at once. One for whether the service is covered. Another for what the plan owed them along the way, which is a duty the plan carries no matter how the coverage question turns out.

That second question is easy to skip. It is also the one with clocks attached.

Deadlines are easier to prove than medical judgements. A date on a letter is a fact anyone can check against a calendar. Whether care was reasonable is an argument.

Which parts does this list leave out?#

Three of them, and the count in the title is what leaves them out. Naming them plainly is cheaper than being wrong later. Prescription drug plan coverage lives one shelf over, in part 423, the Voluntary Medicare Prescription Drug Benefit. Payment rates live in part 414, Payment for Part B Medical and Other Health Services. Hospice rules live in part 418, Hospice Care, which part 409 names in its own text.

None of them is a footnote. A question about a drug plan sits outside the five entirely, even though drugs given in a hospital or under Part B are covered inside 409 and 410. Miss that and you send someone to the wrong shelf.

Counts are promises to the reader. Five is a teaching number. Eight is the working set. The shelf itself holds twenty four, parts 405 to 428, and knowing that is the difference between a number you memorised and a number you checked:

• Part 405. Claims, decisions and appeals.
• Part 409. Hospital, skilled nursing, home health.
• Part 410. Doctor visits, outpatient care, equipment, prevention.
• Part 422. Medicare Advantage plans and their duties.
• Part 424. The conditions met before anything is paid.

Add 423 for drugs. Add 414 for rates. Add 418 for hospice. Memorise five. Remember eight. Then remember that eight is a choice, not an inventory: 412 sets what a hospital is paid, 419 does the same for outpatient departments, and 411 is titled Exclusions from Medicare and Limitations on Medicare Payment. None of the three is in the eight, and each one decides money.

Any count in a title is a promise. One that quietly drops drug plan coverage is worth breaking on purpose.

Which part do you open for your own denial?#

Begin with your own question, in your own words, before you go near a number. Was the service covered at all? Was the process handled properly? Was some condition never met before payment could happen? Three questions, and each one points at a different room in the same book.

Covered at all sends you to part 409 for a hospital question, and to part 410 for nearly everything else. Handled properly sends you to part 405, or to part 422 when a private plan is involved. Never met sends you to part 424, the shortest trip of the three.

Then check the date. That is the step people skip.

Printed editions carry the year they were compiled. The Medicare parts are compiled each October, once a year, every year. Online, the currency date sits near the top of the page. So a rule that changed in June is missing from a book compiled the previous October. A correct citation can still be a stale one.

Think of a part number as a street address. The address holds for decades. The building at that address is rebuilt every October, which is why the date matters as much as the number.

Once you hold the address, the rule behind a letter becomes a short job. The pillar on reading the federal rulebooks covers the ground around it.

Any parent holding a bill they do not understand can do this at the kitchen table in an afternoon, with a phone and nobody’s help. Name the question. Pick the part. Open it. Check the date.