Each and every time I review a Medicare Supplement or a Medicare Advantage plan with a prospective client, I say the same thing: “Don’t count on this policy if you are travelling abroad.” The Medicare Rights Center publishes an online column, “Dear Marci,” which addressed this travel subject admirably.
Both Original Medicare and Medicare Advantage Plans cover emergency or urgently needed services that you receive anywhere in the United States or its territories.
If you have a Medicare Advantage Plan, be aware that if you are receiving emergency or urgently needed services:
• Your plan cannot require you to see an in-network provider
• You do not need a referral
• There are limits on how much your plan can bill you if you receive emergency care while out of your plan’s network
• Your plan must cover medically necessary follow-up care related to the medical emergency if delaying care would endanger your health
• You have the right to appeal if your plan does not cover your care
If your condition was not an emergency but appeared to be an emergency at the time, Original Medicare or Medicare Advantage must still cover your care. For example, let’s say you have chest pain that you think may be a heart attack. If you go to the emergency room and doctors discover that your pain is heartburn, your care should still be covered because the situation appeared to be an emergency.
If your Medicare Advantage Plan denies coverage of an emergency or urgently needed service because you saw an out-of-network provider or failed to get a referral or prior authorization, you should appeal their denial. You should ask your doctor to provide medical documentation that the services you needed were emergency or urgently needed services. If you need assistance appealing the denial contact your State Health Insurance Assistance Program (SHIP). In California it is known as HICAP.
Medicare generally does not cover medical care that you receive while traveling outside the U.S. and its territories. However, Original Medicare and Medicare Advantage Plans must cover care you receive outside the U.S. in certain circumstances:
• Medicare will pay for emergency services in Canada if you are traveling a direct route, without unreasonable delay, between Alaska and another state, and the closest hospital that can treat you is in Canada.
• Medicare will pay for medical care you get on a cruise ship if you get the care while the ship is in U.S. territorial waters. This means that the ship is in a U.S. port or within six hours of arrival or departure from a U.S. port.
• In limited situations, Medicare may pay for non-emergency inpatient services in a foreign hospital (and any connected provider and ambulance costs.) Your care is covered if the hospital is closer to your residence than the nearest available U.S. hospital. This may happen if, for example, you live near the border of Canada or Mexico.
Some Medigap policies provide coverage for travel abroad. Medigap plans C through G, M, and N cover 80% of the cost of emergency care abroad. Check with your policy for specific coverage rules.
Medicare Advantage Plans may also cover emergency care abroad. Contact your plan for more information about its costs and coverage rules.
Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 27 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail firstname.lastname@example.org or visit him on the web at www.harrythal.com.