Readers of the blog often ask me if Medicare will provide any coverage or reimbursement while they’re in Mexico, and if so, under what circumstances.
I had some free time this morning while I was waiting for Linda to wake up, so I did some research and found the answers at Medicare.gov. That’s the official U.S. government website for Medicare.
This information was taken directly from Medicare publication #11037 which was last revised in April of 2018.
Medicare coverage outside the United States is limited
In most situations, Medicare won’t pay for health care or supplies you get outside the U.S.
The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
Below are some of the exceptions that would allow you to get coverage outside the U.S. under Original Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance).
When does Medicare cover health care services in a foreign hospital?
There are 3 situations when Medicare may pay for certain types of health care services you get in a foreign hospital (a hospital outside the U.S.):
- You’re in the U.S. when you have a medical emergency, and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.
- You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable delay” on a case-by-case basis.
- You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether it’s an emergency.
Remember, in these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.
What kind of health care services does Medicare pay for in the 3 situations described above?
Original Medicare covers these services:
- Part A covers inpatient hospital care (care you get when you’ve been formally admitted with a doctor’s order to the foreign hospital as an inpatient). For more information on understanding your hospital status, visit Medicare.gov/publications to view the publication “Are You a Hospital Inpatient or Outpatient?”
- Part B covers emergency ambulance and doctor services you get immediately before and during your covered foreign inpatient hospital stay. However, if Medicare doesn’t cover your hospital stay and/or you get ambulance and doctor services outside the hospital after your covered hospital stay ends, Medicare generally won’t pay for these services. For example, Medicare won’t cover return ambulance trips home.
- Part B covers non-emergency doctor and ambulance services that you get immediately before and during your covered foreign inpatient hospital stay. However, if Medicare doesn’t cover your hospital stay and/or you get doctor services outside the hospital, Medicare generally won’t pay for these services. For example, Medicare won’t cover doctor services you get in Canada after your covered Canadian hospital stay ends.
Remember, Medicare only pays for its share of services covered by Original Medicare. If you only have Part A, Medicare only covers inpatient hospital care.
Does Medicare pay for dialysis treatments when I travel outside the U.S.?
Unless it’s one of the 3 situations described above, Medicare doesn’t cover dialysis when you travel outside the U.S.
Does Medicare pay for prescription drugs outside the U.S.?
Medicare drug plans can’t cover prescription drugs you buy outside the U.S. Call your drug plan for more information.
Will Medicare pay for medically necessary health care services I get on a cruise ship?
Medicare may cover medically necessary health care services you get on a cruise ship in these situations:
- The doctor is allowed under certain laws to provide medical services on the cruise ship.
- The ship is in a U.S. port or no more than 6 hours away from a U.S. port when you get the services, regardless of whether it’s an emergency.
Medicare doesn’t cover health care services you get when the ship is more than 6 hours away from a U.S. port.
What do I pay if I get Medicare-covered services outside the U.S.?
Except in the limited situations described above, Medicare doesn’t pay for health care services you get outside the U.S. If your circumstances don’t meet these limited exceptions, you pay the full cost to the health care provider.
If your situation matches one of the exceptions in this fact sheet and Medicare covers the items or services you get, you still pay the coinsurance or copayments and deductibles you would normally pay if you got these same services or supplies inside the U.S.
Although U.S. hospitals must submit claims to Medicare for you, foreign hospitals aren’t required to file Medicare claims. If you’re admitted to a foreign hospital under 1 of the 3 situations described above, and if that hospital doesn’t submit Medicare claims for you, then you must submit an itemized bill to Medicare for your doctor, inpatient, and ambulance services.
If you got Medicare-covered services on a cruise ship under a situation described in the previous question, the doctor must ordinarily submit the Medicare claim. However, you may also file a claim directly to Medicare in these rare circumstances.
What if I have a Medigap (Medicare Supplement Insurance) policy?
Your Medigap policy may offer additional coverage for health care services or supplies that you get outside the U.S. Standard Medigap plans C, D, F, G, M, and N provide foreign travel emergency health care coverage when you travel outside the U.S. Plans E, H, I, and J are no longer for sale, but if you bought one before June 1, 2010, you may keep it. All of these plans also provide foreign travel emergency health care coverage when you travel outside the U.S.
Medigap plans C, D, E, F, G, H, I, J, M, and N pay 80% of the billed charges for certain medically necessary emergency care outside the U.S. after you meet a $250 deductible for the year. These Medigap policies cover foreign travel emergency care if it begins during the first 60 days of your trip, and if Medicare doesn’t otherwise cover the care. Foreign travel emergency coverage with Medigap policies has a lifetime limit of $50,000.
What if I get my health care from another Medicare health plan rather than Original Medicare?
If you have a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan, your plan may offer additional coverage for health care services you get outside the U.S. Check with your plan before traveling to see what’s covered.
Can I buy travel insurance to help pay for the cost of health care services?
Yes. Because Medicare has limited coverage of health care services outside the U.S., you can choose to buy a travel insurance policy to get more coverage. An insurance agent or travel agent can give you more information about buying travel insurance. Travel insurance doesn’t necessarily include health coverage, so it’s important to read the conditions or restrictions carefully.
Where can I get more information?
- Visit Medicare.gov to find out what Medicare covers.
- Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.