I frequently get calls from clients about why something that seems so basic is not covered by their Medicare plan. It happens whether you are on Original Medicare with a stand-alone prescription drug plan or on an all-inclusive Advantage Plan. This is true of prescription drugs, medical procedures, lab tests, alternative medicine and dental procedures. The basis for the decision to not cover something boils down to whether that drug or service is considered medically necessary, has an effective alternative, or could be considered cosmetic. Based on questions from you, here are some common non-covered items or services that might surprise you. It is very likely that one of these things will come up for you too, so read on.
Prescription Drugs
CMS or Medicare sets guidelines for the insurance companies in terms of prescription drug coverage. However, that doesn’t mean all prescription drugs are covered. There are formularies that the companies present to Medicare for approval. On these formularies, they are only required to cover two drugs in each drug class. So, depending on your plan formulary, and what your Doctor prescribes, your drug may not be covered at all. The insurance company will send you a letter and offer a covered alternative medication to discuss with your Doctor. Another issue that commonly occurs is a denial if there is not an appropriate medical diagnosis tied to that prescription drug. It must be medically necessary, and the drug has to be approved to treat the specific diagnosis. The following is an example.
Special Case with GLP-1
The topic of GLP-1 medications is very hot and all over the media at the time I write this blog. The rising trend in these medications to treat Obesity is wreaking havoc in the insurance world. As of 2024, CMS still considers Obesity to be a lifestyle or cosmetic issue and not classified as a disease. This is despite what the American Medical Association says. The AMA classified Obesity as a disease officially in 2013. The only stride that CMS has made so far is removing this language from the Coverage Manual- “obesity is not an illness”. While that is a start, Medicare will not cover the use of GLP-1 medications to treat Obesity or promote weight loss. These drugs are only covered if the patient has a diagnosis of Type II Diabetes or in some cases, an abnormal A1C lab value. We in the industry do believe this will change within the next eighteen months since more studies are showing major disease states related to Obesity such as heart attacks, stroke, cancer and more. There is a lot of public pressure, so it will be interesting how CMS responds.
Dental Implants and Lasik
First, to be clear, Medicare does not have any Dental or Vision benefits at all. Original Medicare only covers medical expenses and governs the administration of prescription drug benefits. However, Medicare Beneficiaries can obtain Dental and Vision coverage through an Advantage Plan where the insurance company is kicking in these benefits. The other option is to purchase private Dental and Vision plans for folks on Original Medicare with supplement plans. No matter how you get your coverage, the benefits are very similar. Most preventive care is covered. However, I get frequent questions about coverage for dental implants and Lasik vision correction during cataract surgery. Many are surprised when they find out these items are not covered by their Dental and Vision plans. These are considered cosmetic procedures. In the case of cataract surgery, it can be confusing because cataracts are a medical issue. Cataract surgery itself is covered under the medical benefit, however, when your eye surgeon offers to throw in Lasik vision correction while removing cataracts, pay attention. There is likely a pretty significant extra out of pocket cost since the Lasik is cosmetic.
Functional Medicine
According to ifm.org, ‘As a catalyst in the transformation of healthcare, functional medicine treats root causes of disease and restores healthy function through a personalized patient experience’. This is a rising trend, and I am here for it! I love whole wellness and prevention. However, most of the care and treatments you receive from these Functional Practitioners, Concierge Doctors and NPs will be cash out of your pocket. Most of these professionals will not even bill any insurance. In some cases, however, they will bill insurance for the lab work in an attempt to be paid. This is just not traditional medicine, and there isn’t always a clear cut ‘medical necessity’ that can be tied to a billing code for Medicare and insurance companies. However, you can usually use your Health Savings Account to pay for these services and treatments. So, if you happen to have carried an HSA with you into retirement, this is a great option to explore.
Billing Codes are Key
No matter what the medical service or procedure, there will always be a medical necessity requirement with Medicare and insurance companies. It is very important for your provider to bill appropriately and understand what codes are important for medical necessity coverage. There are instances where something is medically necessary and should be covered, but the provider or third party doing the billing is not applying accurate or appropriate billing codes to the claim. Patients get frustrated with the insurance companies first, but many times the problem lies in the provider billing. But that is a whole other blog for another day. Stay tuned!
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
Sources:
