Does Medicare Cover Transportation?

Does Medicare Cover Transportation?

Medicare Advantage plans must provide out-of-area coverage.

What is out-of-area coverage?

Out-of-area coverage is a benefit that pays the Medicare-approved amount for covered services from a provider who is not in the plan's normal service area.

What is a normal service area?

A normal service area is the area in which the plan is required to pay for covered services from providers who are formally affiliated with the plan.

How does Medicare define out-of-area coverage?

Medicare defines out-of-area coverage as follows:

For a Medicare Advantage plan or Medicare Advantage HMO, the plan must cover services from providers who are not formally affiliated with the plan if the services are medically necessary for the diagnosis or treatment of an illness or injury.

For a Medicare Advantage PPO, the plan must cover services from providers who are not formally affiliated with the plan if the services are medically necessary for the diagnosis or treatment of an illness or injury and if the services are available within a 30-mile travel distance from the service area of the plan's normal providers.

How far is the normal service area?

Medicare says the normal service area is “within a reasonable distance.”

Will the Medicare Advantage plan determine how far is considered “reasonable?

”.

The Medicare Advantage plan may determine how far is reasonable. However, reasonable can mean different things to different plan sponsors. For example, it may mean within a 30-mile radius.

What if the Medicare Advantage plan determines that the normal service area is 30 miles or more?

The Medicare Advantage plan must offer out-of-area coverage to its members when medically necessary.

What if the plan determines that out-of-area coverage is not medically necessary?

The plan must still offer out-of-area coverage, but it does not have to pay the Medicare-approved amount for the covered services. In that case, the plan must follow its usual copayment and coinsurance provisions.

Are there any exceptions to the out-of-area coverage requirement?

Yes. Out-of-area coverage is not required if any of the following are true:

The member lives and gets services in an area where there is no Medicare-approved provider.

The provider is not qualified to provide services under Medicare.

The provider does not accept assignment or is not in an appropriate specialty to provide the covered services.

The provider is not able to furnish the level of care required.

The provider is not accessible by the member.

For a Medicare Advantage HMO, the member is enrolled in a managed care delivery system and has access to the out-of-area provider through the managed care delivery system.

What is the definition of a Medicare-approved provider?

A Medicare-approved provider is any provider included on the Medicare provider-enrollment list (which can be found at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/2017-2018-Part-C-HMO-HMO-PFFS-CMS-Tools.pdf).

What if the service area of the plan's normal providers is a 30-mile radius?

If the plan covers services from providers who are not formally affiliated with the plan and the service area of the plan's normal providers is a 30-mile radius, then the out-of-area providers must be within a 30-mile radius of the service area of the plan's normal providers.

What if the out-of-area provider is not within the 30-mile radius?

If the out-of-area provider is not within the 30-mile radius, then the plan is not required to pay for covered services from that provider. However, the plan is still required to provide out-of-area coverage, but it does not have to pay the Medicare-approved amount for the covered services. In that case, the plan must follow its usual copayment and coinsurance provisions.

What is a managed care delivery system?

A managed care delivery system is an organized network of health care providers that offers coordinated or integrated health care services to its members.

When does a managed care delivery system have to provide out-of-area coverage?

A managed care delivery system must offer out-of-area coverage if the member is enrolled in the system and has access to out-of-area providers through the managed care delivery system.

Is the plan required to pay for out-of-area coverage if the plan does not consider it medically necessary under the plan's usual coverage rules?

No. The Medicare Advantage plan does not have to pay for the service. In that case, the plan must follow its usual copayment and coinsurance provisions.

What are some different ways that a Medicare Advantage plan can offer out-of-area coverage?

A Medicare Advantage plan can offer out-of-area coverage in any of the following ways:

Covered services from out-of-area providers can be covered in the same way as covered services from in-area providers.

Covered services from out-of-area providers can be covered at the plan's usual Medicare-approved amount.

Covered services from out-of-area providers can be covered at the plan's usual Medicare-approved amount with a copayment and coinsurance.

Covered services from out-of-area providers can be covered at the plan's usual Medicare-approved amount with a copayment, coinsurance, and a deductible.

Covered services from out-of-area providers can be covered at the plan's usual Medicare-approved amount with a copayment, coinsurance, and coinsurance.

Covered services

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