Medicare Coverage Rules: Items and Services Outside the U.S. and More
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Items and Services Furnished Outside the United States (U.S.) - Medicare
Most items and services furnished or delivered outside the U.S. are not covered, including when the beneficiary was within the U.S. when the contract to purchase the item was made or the item was purchased from an American firm. Payment will not be made for a medical service (or a portion thereof) that was subcontracted to another provider or supplier located outside the U.S.Medicare pays for provider professional services that are furnished in the U.S., except for certain limited services as described below under Exceptions. The Centers for Medicare & Medicaid Services (CMS) recognizes the following as being within the U.S.: • The 50 States; • The District of Columbia; • The Commonwealth of Puerto Rico; • The Virgin Islands; • Guam; • The Commonwealth of the Northern Mariana Islands; • American Samoa; and • Territorial waters adjoining the land areas of the U.S. (for services furnished onboard a ship). A hospital is considered outside the U.S. if it is not physically located in one of the jurisdictions listed above, even if it is owned or operated by the U.S. Government.
Exceptions The following services are covered: • Emergency inpatient hospital services furnished at a foreign hospital provided the foreign hospital is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency. One of the following conditions must exist: ◦ The beneficiary was physically present in the U.S. at the time of the emergency that necessitated inpatient services; or ◦ The emergency arose in Canada while the beneficiary was traveling, by the most direct route and without unreasonable delay between Alaska and another State; • Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the U.S. provided the hospital is closer to, or substantially more accessible from, the beneficiary’s U.S. residence than the nearest participating U.S. hospital that is adequately equipped to deal with and available to treat the illness or injury; • Physician and ambulance services furnished in connection with a covered foreign hospitalization. Payment will not be made for any other Part B outpatient, medical, and other health services that are furnished outside the U.S.; • Services furnished onboard a ship in a U.S. port or furnished within 6 hours of when the ship arrived at or departed from a U.S. port. Services that do not meet this requirement are considered furnished outside U.S. territorial waters, even if the ship is of U.S. registry; • Physician and ambulance services furnished in Canada and covered by the Railroad Retirement Board to a Railroad Retirement beneficiary in connection with covered hospital services; and • Services for a beneficiary who has elected the religious nonmedical health care benefit; however, the receipt of medical services may revoke the religious nonmedical health care benefit.
B) Items and Services Required as a Result of War 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 are not covered.
C) Personal Comfort Items and Services Personal comfort items will not be covered because these items do not meaningfully contribute to the treatment of a beneficiary’s illness or injury or the functioning of a malformed body member. Some examples of personal comfort items are: • Radios; • Televisions; and • Beauty and barber services, except as described below under Exceptions.
When a beneficiary requests a personal comfort item, you should inform him or her that there is a specified charge for the item. The specified charge may not exceed the customary charge, and future charges may not be more than the amount specified. You cannot require the beneficiary to request non-covered items or services as a condition of admission or continued stay.
Exceptions Certain basic personal services that residents in Skilled Nursing Facilities (SNF) and general psychiatric hospitals need and cannot perform for themselves are covered. Some examples include: • Shaves; • Haircuts; • Shampoos; and • Simple hair sets. These services may be considered ordinary patient care and covered costs are reimbursable under Part A when they are: • Furnished by a long-stay institution; • Included in the flat rate charge; and • Routinely furnished without charge to the beneficiary.
D) Routine Physical Checkups; Certain Eye Examinations, Eyeglasses and Lenses; Hearing Aids and Examinations; and Certain Immunizations The following routine items and services are not covered: • Routine or annual physical checkups, except as described in the Exceptions Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary below • Physical examinations that are performed without a specific sign, symptom, or beneficiary complaint necessitating the service or that are required by third parties (for example, insurance companies, business establishments, or Government agencies); • Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; • Eye refractions furnished by all practitioners for any purpose; • Eyeglasses and contact lenses; • Examinations for hearing aids; • Hearing aids; and • Immunizations, except as described in the Exceptions Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary given below.
Exceptions The following items and services are covered: • Physician services performed in conjunction with an eye disease (for example, glaucoma and cataracts); • Services performed incident to physician services in conjunction with an eye disease; • One pair of eyeglasses or contact lenses after each cataract surgery with insertion of an intraocular lense; • Vaccinations directly related to the treatment of an injury or direct exposure to a disease or condition (for example, antirabies treatment and immune globulin); • Vaccinations that are specifically covered by statute (for example, seasonal influenza virus, pneumococcal, and Hepatitis B); • A reasonable supply of antigens (not more than a 12-week supply that has been prepared for a particular beneficiary) a doctor of medicine (MD) or a doctor of osteopathy (DO) has prepared after examining the beneficiary and determining a plan of treatment and dosage regimen. A different physician may administer the antigens; and • Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve and are indicated only when hearing aids are medically inappropriate or cannot be utilized due to: ◦ Congenital malformations; ◦ Chronic disease; ◦ Severe sensorineural hearing loss; or ◦ Surgery. These devices, which are payable as prosthetic devices, include: • Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or the auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays; and • Osseointegrated implants that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.