What are 3 services not covered by Medicare?

Medicare doesn't cover everything. If you need services Part A or Part B doesn't cover, you'll have to pay for them yourself unless:

You have other coverage (including Medicaid ) to cover the costs.
You're in a Medicare Advantage Plan or Medicare Cost Plan that covers these services. Medicare Advantage Plans and Medicare Cost Plans may cover some extra benefits, like fitness programs and vision, hearing, and dental services.

Some of the items and services Medicare doesn't cover include:

Long-Term Care (also called custodial care [glossary] )
Most dental care
Eye exams (for prescription glasses)
Dentures
Cosmetic surgery
Massage therapy
Routine physical exams
Hearing aids and exams for fitting them
Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
Covered items or services you get from an opt-out doctor or other provider (except in the case of an emergency or urgent need)

Find out if Medicare covers a test, item, or service you need.

If you're not lawfully present in the U.S., Medicare won't pay for your Part A and Part B claims, and you can't enroll in a Medicare Advantage Plan or a Medicare drug plan.

A patient may ask for a service that Medicare does not consider medically reasonable and necessary under the circumstances. For instance, the patient wants the service more frequently than Medicare allows or for a diagnosis that Medicare does not cover. You can often verify coverage information by researching the service on the payer’s website. If the patient’s policy coverage is unclear, inform the patient that it may result in an out-of-pocket expense before performing the service.

There are two resources to help you determine if Medicare considers services to be medically reasonable and necessary: national coverage determinations (NCDs) and local coverage determinations (LCDs). These documents provide information regarding CPT and Healthcare Common Procedure Coding System (HCPCS) codes, ICD-10 codes, billing information, as well as service delivery requirements.

The Centers for Medicare & Medicaid Services (CMS) offers an online, searchable Medicare Coverage Database that allows anyone to freely search NCDs, LCDs, and other Medicare coverage documents. The database has quick and advanced search capabilities to search by geography, Medicare contractor, key words, CPT codes, HCPCS codes, and ICD-10 codes.

Commercial insurance companies and some Medicaid payers will have similar types of information about their coverage guidelines on their websites. Stay up-to-date on these policies for your local payers to ensure claims are processed as medically reasonable and necessary.

Inform Patient of Potential Financial Responsibility

In all cases, if the patient’s policy coverage is unclear, inform the patient that they may be responsible for paying for the service. This should be done before you provide the service.

If a Medicare patient wishes to receive services that may not be considered medically reasonable and necessary, or you feel Medicare may deny the service for another reason, you should obtain the patient’s signature on an Advance Beneficiary Notice (ABN). Medicare requires an ABN be signed by the patient prior to beginning the procedure before you can bill the patient for a service Medicare denies as investigational or not medically necessary. Otherwise, Medicare assumes the patient did not know and prohibits the patient from being liable for the service.

You must explain the ABN to the patient and the patient must sign it before the service is provided. The ABN must have the following three components:

Detailed description of the service to be provided;
Estimated cost within $100; and
Reason it is believed Medicare will not cover the service.

If an ABN is obtained, attach modifier -GA (waiver of liability statement issued as required by payer policy, individual case) to the line item(s) within the claim to indicate the patient has been notified.

The CMS website has additional information and downloadable ABNs in several formats.

Non-covered Services

Certain services are never considered for payment by Medicare. These include preventive examinations represented by CPT codes 99381-99397. Medicare only covers three immunizations (influenza, pneumonia, and hepatitis B) as prophylactic physician services. Cosmetic procedures are never covered unless there is a medically-necessary reason for a procedure. In this instance, you should document and code it as such. Services rendered to immediate relatives and members of the household are not eligible for payment.

Non-covered services do not require an ABN since the services are never covered under Medicare. While not required, the ABN provides an opportunity to communicate with the patient that Medicare does not cover the service and the patient will be responsible for paying for the service. Pre-emptive communication through a voluntary ABN can prevent negative patient perceptions of your practice and facilitate collections. These modifiers are not required by Medicare, but do allow for clean claims processing and billing to the patient. There are three modifiers to consider when dealing with non-covered services:

-GX – Notice of liability issued, voluntary payer policy. A -GX modifier should be attached to the line item that is considered an excluded, non-covered service. The -GX modifier indicates you provided the notice to the beneficiary that the service was voluntary and likely not a covered service.
-GY – Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, and is not a contract benefit. If you do not provide the beneficiary with notice that the services are excluded from coverage, you should append modifier -GY to the line item. Modifier -GY indicates a notice of liability (ABN) was not provided to the beneficiary.
-GZ – Item or service expected to be denied as not reasonable and necessary. Modifier -GZ should be added to the claim line when it is determined an ABN should have been obtained, but was not.

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Australians make more than 150 million visits to a GP every year. Medicare – our public health insurance system – helps pay for these visits.

If you have a Medicare card, you can access a range of health care services for free or at a lower cost, including:

medical services by doctors, specialists and other health professionals
hospital treatment
prescription medicines.

The Medical Benefits Schedule (MBS) lists the medical services covered by Medicare.

The schedule includes an MBS fee for each service. This is the amount (or benefit) the Australian Government thinks the service should cost. The schedule also includes how much benefit you can claim for each service.

If you spend a lot of money on out-of-hospital medical costs over a year, you may be able to access higher benefits through the Medicare Safety Net.

A Medicare card also gives you access to the Pharmaceutical Benefits Scheme (PBS). This means you only pay part of the cost of many prescription medicines listed on the PBS. The PBS covers the rest of the cost. If you have a concession card, you pay an even lower price.

If you pay a lot for medications in a year, you may be able to get a further discount through the PBS Safety Net.

Medicare also covers diagnostic imaging services such as ultrasound, CT scans, X-rays, MRI scans. Find out more about diagnostic imaging under Medicare.