If you’re a Medicare recipient, you more than likely have come across the term “Medically Necessary” a time or two. When navigating the world of Medicare, the term medically necessary is important. This is because you need to know the coverage for your specific plan.
So, what does this term mean? What defines “necessary” and “unnecessary”? How does this affect you as a beneficiary? Also, what happens if a service isn’t medically necessary?
Defining “Medically Necessary”
HealthCare.gov states that medically necessary services are “health care services or supplies that diagnose or treat an illness, injury, condition, disease, or its symptoms and those standards of medicine.”
The deductible and premiums for treatments fall under Part B; also, it’ll cover services or equipment that treats a specific condition. However, if a service isn’t for treating the condition, you’ll have to pay for it completely out of pocket. Some services like dermatology can be more difficult to understand.
Per CMS, medically necessary services or supplies:
- Are proper and needed for the diagnosis or treatment of your medical condition
- Provided for the diagnosis, direct care, and treatment of your medical condition
- Meet the standards of good medical practice in the local area
Anything “medically necessary” is crucial to the Medicare process because Medicare will only pay for what is to treat an injury or illness.
However, most procedures and medical equipment are typically necessary. You may run into a specific service or piece of medical equipment that needs the approval to be necessary; also, approval is done by your physician to receive coverage.
This is a safeguard in place to help protect the federal government from people ordering unnecessary equipment.
Below are some examples of what could be necessary services:
- Hospice care
- Home health care
- Nursing home care
- Hospital care
- Health screenings
- Durable medical equipment
- Ambulance services
- Physician visits
“Unnecessary” Services and Equipment
There are specific services, equipment, and prescriptions that aren’t medically necessary and won’t have coverage. However, at times supplemental coverage could assist you with the cost of these things.
For example, by purchasing dental coverage you reduce the cost of dental care.
Some examples may include:
- Dental exams, extractions, cleaning, fillings, etc.
- Eye exams, contact lenses, eyeglasses, etc.
- Hearing aids, hearing exams, etc.
- OTC medications
- Oxygen therapy equipment
- Sleep apnea devices
- Seat lift mechanisms
- Unwarranted therapies
- Excessive procedures used for a diagnosis
- Assisted suicide
- Fertility Treatments
- Weight loss medications
- Erectile dysfunction prescriptions
- Excessive hospital stays
There may be instances, however, where Medicare may cover services it normally wouldn’t cover if already covering a relatable procedure.
What is Medically Necessary under a Medicare Advantage Plan
Medicare Advantage plans cover all medically necessary services under Part A and B. Individual Advantage plans can cover services that aren’t medically necessary under Medicare, such as dental, vision, hearing services, or prescriptions.
While Advantage plans may end up costing more, they usually include more medically necessary coverage than you would typically receive.
When a Service isn’t Medically Necessary
If Medicare decides that your service doesn’t meet its classification of being medically necessary, it doesn’t have coverage. Although, this means that you’re responsible for the cost.
If you find yourself in need of a non-covered service it could be scary; however, reviewing and signing an “Advance Beneficiary Notice of Noncoverage” could benefit you.
This serves as your acknowledgment that you may have to pay for the specifically requested item, service, or supply. Another possible route to take would be a Certificate of Medical Necessity.
Finding Out about Coverage
You may want a document from Medicare that advises you in advance which services have coverage and your portion of costs. Although, if you’re wanting to find out your exact coverage, you can ask for an Advance Coverage decision.
Let’s say you receive Medicare and your physician thinks that Medicare won’t cover a service; the physician can provide you with an “Advance Beneficiary Notice of Noncoverage”.
This notice states what Medicare won’t cover and the explains noncoverage. Although, this provides an estimate for out of pocket costs that you could be responsible.
Appealing a Decision
If Medicare denies your claim after a service, you have the right to appeal the decision. Depending on whether you have a Medicare Advantage plan or Original Medicare, the appeal processes may differ.
However, if you find that you have any additional questions about coverage by Medicare, you can reach out to your local Social Security Administration office or contact your medical provider.
Understanding Medicare can be difficult, working with an agent means you get a personal guide to Medicare. Also, our agents can help you find the most suitable plan for your needs. Call the number above or fill out an online rate form to get started today!