CMS Pub. 100-02, ch. 16, § 130

Members of the Patient’s Household

(Rev. 1, 10-01-03)

A3-3161, HO-260.12, B3-2332

A. General

These are expenses that constitute charges by immediate relatives of the beneficiary or by

members of their household. The intent of this exclusion is to bar Medicare payment for

items and services that 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 providers to immediate relatives of the owner(s) of the

provider. It also applies to services rendered by physicians to their immediate relatives

and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.

B. Immediate Relative

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; and

• Spouse of grandparent and grandchild.

NOTE 1: A brother-in-law or sister-in-law relationship does not exist between the

physician, supplier or owner of a provider (or supplier) and the spouse of his wife’s or

her husband’s brother or sister.

NOTE 2: A father-in-law or mother-in-law relationship does not exist between a

physician or the owner of a provider and his or her spouse’s stepfather or stepmother.

A step-relationship and an in-law relationship continues to exist even if the marriage

upon which the relationship is based is terminated through divorce or through the death

of one of the parties. For example, if a provider treats the stepfather of the owner after

the death of the owner’s natural mother or after the owner’s stepfather and natural mother

are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the

death of their spouse, the services are considered to have been furnished to an immediate

relative, and therefore, are excluded from coverage.

C. Members of Patient’s Household

These are persons 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.

D. Charges for Provider Services

Payment is not made under Part A or Part B for items and services furnished by providers

to immediate relatives of the owner(s) of the providers. This exclusion applies whether

the provider is a sole proprietor who has an excluded relationship to the patient, or a

partnership in which even one of the partners is related to the patient.

E. Charges for Physician and Physician-Related Services

This exclusion applies to physician services, including services of a physician who

belongs to a professional corporation, and services furnished incident to those services

(for example, by the physician’s nurse or technician) if the physician who furnished the

services or who ordered or supervised services incident to their services has an excluded

relationship to the beneficiary.

Professional corporation means a corporation that is completely owed by one or more

physicians, and is operated for the purpose of conducting the practice of medicine,

osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health

care professionals as authorized by State law. Any physician or group of physicians

which 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.)

F. Charges for Items Furnished by Nonphysician Suppliers

This exclusion applies to charges imposed by a nonphysician supplier that is not

incorporated, whether the supplier is owned by a sole proprietor who has an excluded

relationship to the patient, or by a partnership in which even one of the partners is related.

It 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.