There are several reasons why Medicare may not cover a service. First, an individual may not be eligible for Medicare Part A or Part B (Original Medicare), or likewise, for a Medicare Advantage Plan.
In order to be eligible for Medicare, you must meet one of two conditions. First, you must be age 65 or over. Or, you may be under age 65, but have a qualifying disability that is officially recognized and meets the requirements for Medicare’s coverage.
Another reason that a service may not be covered is if the doctor, health care provider, and / or provider of the medical supplies that are being purchased does not accept Medicare assignment.
When a doctor or health care provider accepts Medicare assignment, it means that they accept payment in full the amount(s) that Medicare pays on all Medicare-related claims for covered services and supplies for a Medicare enrollee. Therefore, accepting Medicare assignment means that these providers, enrollees, and Medicare itself have entered into an agreement that outlines the payment relationship between the parties.
The agreement essentially stipulates that in Original Medicare (Part A and Part B), Medicare will pay its portion to the health care providers that provide care to the Medicare enrollees – and that the health care providers will not collect additional payment from these enrollees other than the amount of the applicable deductible and / or co-insurance.
Even if an individual is enrolled in Original Medicare, and if their provider / supplier accepts Medicare assignment, there are still some services and items that Medicare does not cover. In most instances, this is because the item or service is not considered to be medically necessary to the enrollee.
Some of the items and services that are not covered by Medicare include the following:
While Original Medicare (Medicare Parts A and B) may not cover certain services, there is an alternate method of obtaining additional coverage. This is through opting for Medicare coverage through Medicare Part C – also known as Medicare Advantage.
A Medicare Advantage plan is an alternative way for Medicare enrollees to receive Part A and Part B coverage. These plans, offered by private insurance companies, are required to provide all of the same benefits that are included in Original Medicare – however, they will typically also include additional coverage such as dental and vision care. Many Medicare Advantage plans may also offer coverage such as wellness benefits and preventive benefit options.
Another way to obtain additional coverage that is not offered via Original Medicare is to purchase a Medicare Supplement insurance policy. These plans, also known as Medigap insurance, can help to fill in the “gaps” in coverage that are left by Medicare such as the payment of deductibles, co-payments, and / or co-insurance that would otherwise need to be paid out-of-pocket by a Medicare enrollee. Depending on the policy that is chosen, these plans can also pay out additional benefits, too, such as coverage during foreign travel emergencies.
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