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Medicare Does Not Cover What You May Think

November 05, 20232 min read

There are approximately 64 million people enrolled in Medicare with 36 million enrolled in the original Medicare plan and about 28 million enrolled in Medicare Advantage and other health plans, according to CMS.gov. These people count on this coverage to pay for doctor's visits, prescribed medications, and a standardized level of healthcare.

There are actually five parts to Medicare, but the original Medicare Parts are A & B. The original parts only cover those things that are deemed medically necessary, and it is the insurance company that makes this determination. If we just look at Medicare Part A, it helps covers inpatient hospitalizations, skilled nursing facility admissions, hospice, home health, and some outpatient services. While Medicare Part B convers doctor's appointments and other health care providers, and some outpatient services. Other items covered include durable medical equipment like wheelchairs, walkers and hospital beds; some preventive services like yearly wellness visits, vaccines or shots; and screenings.

Additionally, Medicare B will cover ground ambulance transportation, if traveling any other way would jeopardize your health, and the services from a hospital or skilled nursing facility is medically necessary. If there is a written order from a doctor stating that nonemergency transport is medically necessary, as in the case of a person with end stage renal disease needing transport to a kidney dialysis center, Medicare B may cover the cost.

Medically Necessary???

If the physician recommends that you receive treatments or services more often than Medicare covers, you may end up paying the cost for some or all of the services. Make sure to ask the doctor if these services will be covered and if they are medically necessary.

In summary, Medicare.gov states that coverage is based on the following:

  • Federal and state laws

  • National coverage decisions made by Medicare

  • Local coverage decisions made by companies in each state that process Medicare claims. It is these companies that determine whether something is medically necessary and should be covered in their area.

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