Not Covered 

While original Medicare does cover many medically necessary services and the number of preventive services covers continues to grow, it is important to reiterate on the services original Medicare does not cover and the importance of purchasing Medicare insurance to help offset the out-of-pocket expenses, or cost-sharing, that the Medicare beneficiary is responsible for paying.  Original Medicare is not complete coverage.  In addition to the high deductibles and cost-sharing there are numerous services that original Medicare just does not cover.  Your Medicare Supplement plan only covers Medicare approved services. It is important to point out that if original Medicare does not cover it, supplement plan will not cover it either.

Your Medicare Supplement Plan Only Covers Medicare Approved Services

Bringing attention to the fact that your Medicare Supplement only covers Medicare approved services, it is equally important to provide information regarding non-approved services and procedures, or services and procedures not approved by original Medicare.  The following is a partial list, but a list of the most popular services or procedures, that Medicare Pathways wants to point out that your Medicare supplement plan only covers Medicare approved services.

  • Alternative medicine, including experimental procedures and treatments, acupuncture, and chiropractic services except when manipulation of the spine is medically necessary to fix a subluxation of the spine. A subluxation is when one or more of the bones of the spine move out of position;
  • Most care received outside of the United States;
  • Cosmetic surgery, unless it is needed to improve the function of a malformed part of the body;
  • Most dental care;
  • Hearing aids or the examinations for prescribing or fitting hearing aids, except for implants to treat severe hearing loss in some cases.;
  • Personal care or custodial care unless homebound and receiving skilled care, and nursing home care, except in a skilled nursing facility, if eligible.  Custodial care is personal care that does not require the continuing attention of trained medical or paramedic personnel and serves to assist an individual in the activities of daily living.
  • Housekeeping services to help you stay in your home, such as shopping, meal preparation, and cleaning, unless you are receiving hospice care;
  • Non-medical services, including hospital television and telephone, a private hospital room, canceled or missed appointments, and copies of x-rays;
  • Most non-emergency transportation, including transportation in a specially equipped motor vehicle for transporting convalescing or handicapped people;
  • Some preventive care, including routine foot care;
  • Most vision (eye) care, including eyeglasses and examinations for prescribing or fitting eyeglasses or contact lenses, except after cataract surgery;
  • Items and services that are required as a result of war or an act of war and that occur after the effective date of the beneficiary’s current entitlement date are not covered.
  • Keep in mind that even for original Medicare-covered services, Medicare does not usually pay 100%.  There are some exceptions with regard to preventive screenings and examinations that are provided at zero cost to the Medicare beneficiary. 
  • Non-physician services furnished to hospital and Skilled Nursing Facility (also known as “SNF”) patients that are not provided directly or under arrangement.  In general, non-physician services furnished to original Medicare Part A and Part B hospital in patients and Part A Skilled Nursing Facility in patients that are not provided directly or under arrangement are not covered.
  • Services related to and required as a result of services that are not covered.  Medical and hospital services that are related to and required as a result of services that are not covered as not medically reasonable and necessary or excluded from coverage will not be paid. Some examples of these services are: Cosmetic surgery; non-covered organ transplants; and services related to follow-up care or complications that require treatment during a hospital stay in which a non-covered service is performed.
  • Services and supplies that have been denied as bundled or included in the basic allowance of another service.  The following services and supplies that have been denied as bundled or included in the basic allowance of another service will not be paid: fragmented services included in the basic allowance of the initial service; prolonged care (indirect); physician standby services; case management services (i.e., telephone calls to and from the beneficiary); and supplies included in the basic allowance of a procedure.
  • Items and services reimbursable by other organizations or furnished without charge.
  • Physical examinations that are performed without a specific sign, symptom, or beneficiary complaint necessitating the service or that are required by third parties (i.e., insurance companies, business establishments, or Government agencies).  Payment will not be made for items and services when payment has been made or can reasonably be expected to be paid promptly under: automobile insurance; no-fault insurance; liability insurance; or workers’ compensation law or plan of the United States or a state.
  • Items and services authorized or paid for by a government entity.  In general, payment will not be made for the following items and services authorized or paid for by a government entity:  those that are furnished by a government or non government provider or other individual at public expense pursuant to an authorization issued by a Federal agency (i.e., Veterans Administration authorized services). 

Your Medicare Supplement Plan Only Covers Medicare Approved Services

While it is very important to point out the numerous services and procedures original Medicare Part A and Part B does cover, it is equally as important to identify the services not covered.  If you undergo a procedure or receive a service that is not an approved Medicare service then you, the Medicare beneficiary, will be responsible for 100% of the costs.  It is also equally important to point out that if Medicare doesn’t cover it, your supplement plan won’t cover it either.  A Medicare supplement plan comes in and pays, or fills in the gaps, of what original Medicare does not pay.  Medicare supplement plans will not pay any portion of a non-approved Medicare service or procedure.  Some Medicare Advantage plans (also known as “Part C”), may cover some of the above identified items or services not covered by original Medicare Part A and Part B. 

Medicare Advantage Plans May Cover Some Services Not Covered by Medicare

A Medicare Pathways Benefit Specialist can review the Medicare Advantage plans offered in your area to determine if a plan is available that provides coverage for some of the above-identified services not covered by original Medicare Part A or Part B.  It is important to be aware of the non-approved Medicare services to avoid costly procedures or “extras” that the Medicare beneficiary subsequently becomes responsible.  In an attempt to provide a better explanation of Medicare supplement plans it is important to understand Medicare approved services and the fact that your Medicare supplement plan only covers Medicare approved services. 

If you are shopping for Medicare insurance such as a Medicare Advantage plan, Medicare Supplement plan, or Prescription Drug Plan please call a Benefit Specialist at Medicare Pathways who can assist you in reviewing your options and finding the most affordable and most appropriate Medicare insurance plan for your needs.  You can also Request a Quote and a Benefit Specialist will contact you.

 

Stay informed!  Visit our News Blog!

Medicare Pathways:  1-866-466-9118.