Are There Any Restrictions On The Services That Medicare Covers?

Typically, Medicare covers medically necessary items, tests and services. Excessive, unrelated and unnecessary procedures, and those that are not covered services under Medicare, will not be paid for by the program, nor will services you receive outside of the U.S.

Medicare Will Not Cover Unreasonable Or Unnecessary Services

In its coverage for Medicare Part A and Part B, Medicare is quite clear on this, by saying that it covers medically necessary services, tests and items. Most of this will be determined after your health care provider submits the claim to Medicare for payment. The claim will be reviewed, and Medicare will look to see whether the cost could have been avoided.

You may find that Medicare does not cover services that you could have received at home, if you got them in a hospital or other health care facility. Medicare also has restrictions for its coverage of diagnostic tests and procedures. Sometimes tests are covered for regular screenings but not for diagnostic purposes. Medicare will also pass judgment if they deem these procedures excessive, and the same goes for excessive therapy.

If you are not showing symptoms for and do not have a diagnosis that warrants a test, Medicare may not cover it. You will also have to pay out of your own pocket for any unnecessary services, therapies unrelated to your treatment, or for hospital stays that extend past your 60 lifetime reserve days. 

Medicare Covers Only Its Covered Items And Services

Just because a test, item or service is medically necessary does not mean that Medicare will cover it. Part A and Part B have quite clear coverage status answers on the Medicare website and app, so please refer to the official Medicare resources to find out whether an item, test or service will be covered.

Medicare also has notable gaps in coverage. Some of these non-covered services include custodial care, which does not require the skill of a medical provider. Medicare will pay for skilled services you receive at the same time you are receiving custodial care, but does not cover help with those basic functions such as bathing, dressing and feeding. If you receive custodial care as part of hospice care, Medicare will cover it as long as it’s deemed reasonable and necessary for your condition.

Gaps In Medicare Coverage

Medicare does not cover annual physicals. It also does not have coverage for routine dental, vision or hearing care. Medicare also lacks coverage for long term care, chiropractic care, acupuncture, cosmetic surgery, and routine podiatry care. You must purchase Medicare Part D for prescription drug coverage.

Medicare Will Not Cover Services Resulting From Non-Covered Treatment

If you go to a chiropractor and are left with a neck injury, you will have to pay for your recovery. Likewise, if you receive cosmetic surgery or an elective procedure and suffer complications, Medicare will not pay for your revisions, wound care or any health services directly related to that non-covered procedure.

Medicare Covers Services In The U.S. And Its Territories

Medicare will not cover services you receive outside of the United States, U.S. territories, and its immediate waters, except in specific exceptions. If you would like coverage for foreign travel, you can purchase one of six Medicare Supplement plans that offers that coverage.