The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service.
Most Medicare Advantage Plans offer coverage for things that aren't covered by Original Medicare, like vision, hearing, dental, and wellness programs (like gym memberships). Plans can also cover more extra benefi ts than they have in the past, including services like transportation to doctor visits, overthe-counter drugs, adult day-care services, and other health-related services that promote your health and wellness. Plans can also tailor their benefi t packages to offer these new benefi ts to certain chronically ill enrollees. These packages will provide benefits customized to treat those conditions. Check with the plan to see what benefi ts are offered and if you qualify. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. In 2019, the standard Part B premium amount is $135.50 (or higher depending on your income).
If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal the decision.
You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, the plan must tell you in writing.
You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:
• The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
• The provider referred you to an out-of-network provider for plan-covered services.
Contact your plan for more information. Get your plan's contact information from a Personalized Search (under General Search), or search by plan name.
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