Beneficiaries and caregivers need to understand when Medicare will cover a procedure. The basic rule is that if a procedure is medically necessary, Medicare will usually pay. There are exceptions, and you might pay more for one doctor or facility than another.
Here are four of the top reasons a procedure might not have coverage. Also, there are things you can do to maximize coverage.
Will Medicare Cover My Necessary Procedure
There are several common procedures and situations that Medicare doesn’t cover, no matter how important they are to your overall health and well-being.
- Routine dental care such as cleanings, fillings, crowns, and dentures
- Routine eye exams and glasses
- Assisted living
- Long-term custodial care in a memory care unit or nursing home
- Medical care while traveling outside the U.S.
Fortunately, you can plan for most of these situations by buying additional insurance coverage, including standalone dental, hearing, eye care, long-term care, and travel insurance policies.
Some Medicare Advantage plans already include coverage for eye, dental, and/or hearing care.
The procedure is not “medically necessary” according to Medicare standards. Medicare will only cover procedures that are medically necessary.
Well, Medicare defines “medically necessary” as “healthcare services or supplies to diagnose or treat an illness, injury, condition, disease or its symptoms; then, it must meet the standards of Medicare.”
This means that many elective or cosmetic procedures won’t have coverage. But in some cases, a procedure that ordinarily wouldn’t qualify will have coverage because it’s necessary to treat a medical condition.
For example, if you decide to get surgery to make your nose smaller and more attractive, Medicare will consider this a cosmetic procedure and won’t pay for it.
If you need surgery because you broke your nose in a car accident, Medicare may view nose surgery as medically necessary.
Some things Medicare doesn’t usually cover; such as dental work, can be medically necessary for rare instances. For example, Medicare will pay for tooth extractions to prepare your mouth for treatment for jaw cancer.
Medicare Doesn’t Cover the Doctor, Do they Cover the Procedure
Your Medicare costs can vary depending on your Medicare plan and the healthcare providers you use. If you have Medicare Advantage, you pay more to see a provider who is outside the network.
Original Medicare and Medigap don’t have provider networks, but that doesn’t mean all healthcare providers handle Medicare patients in the same way.
Some providers accept Medicare assignment, which means they have agreed to accept Medicare’s reimbursement rate as full compensation for their services. For example, if Medicare will pay $50 for a doctor visit, a provider who accepts Medicare assignment will not charge more than that.
Some providers take Medicare patients, but they don’t accept Medicare assignment. In most states, these providers may bill you for an “excess charge” of up to 15 percent of the Medicare amount. If the Medicare rate for a doctor visit is $50, you could be responsible for paying $7.50 as excess charges.
Some providers don’t work with Medicare at all. If you see one of these providers, you can seek reimbursement from Medicare, but in the meantime, you may have to pay the provider’s full charge upfront.
You can avoid extra costs by making sure providers accept Medicare. Then, to protect your finances enroll in Plan G that picks up any excess charges.
There’s a Medicare Billing Issue
When providers send their bills to Medicare, every procedure, office visit or test is given a code. Medicare looks at these codes and decides whether and how to pay for the procedure.
If the provider enters the incorrect code, Medicare may deny the claim.
Reviewing your Medicare statements regularly should be a habit. Additionally, you can contact Medicare and your provider if you have questions about coverage.
Often, your provider simply needs to resubmit the claim with the correct code.
Know if Medicare Covers Your Procedure
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