Notice Of Exclusion Of Medicare Benefits printable pdf download

(NEMB)

OTICE OF

XCLUSIONS FROM

EDICARE

ENEFITS

There are items and services for which Medicare will not pay.

• Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits.

Some items and services are not Medicare benefits and Medicare will not pay for them.

• When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it,

personally or through any other insurance that you may have.

The purpose of this notice is to help you make an informed choice about whether or not

you want to receive these items or services, knowing that you will have to pay for them yourself.

Before you make a decision, you should read this entire notice carefully.

Ask us to explain, if you don’t understand why Medicare won’t pay.

Ask us how much these items or services will cost you (Estimated Cost: $_____________).

Medicare will not pay for: ________________________________________________

______________________________________________________________________;

□

Because it does not meet the definition of any Medicare benefit.

□

Because of the following exclusion * from Medicare benefits:

□ Personal comfort items.

□ Routine physicals and most tests for screening.

□ Most shots (vaccinations).

□ Routine eye care, eyeglasses and examinations.

□ Hearing aids and hearing examinations.

□ Cosmetic surgery.

□ Most outpatient prescription drugs.

□ Dental care and dentures (in most cases).

□ Orthopedic shoes and foot supports (orthotics). □ Routine foot care and flat foot care.

□ Health care received outside of the USA.

□ Services by immediate relatives.

□ Services required as a result of war.

□ Services under a physician’s private contract.

□ Services paid for by a governmental entity that is not Medicare.

□ Services for which the patient has no legal obligation to pay.

□ Home health services furnished under a plan of care, if the agency does not submit the claim.

□ Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997.

□ Items or services furnished in a competitive acquisition area by any entity that does not have a contract

with the Department of Health and Human Services (except in a case of urgent need).

□ Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist,

when furnished to an inpatient, unless they are furnished under arrangements by the hospital.

□ Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF)

or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF.

□ Services of an assistant at surgery without prior approval from the peer review organization.

□ Outpatient occupational and physical therapy services furnished incident to a physician’s services.

* This is only a general summary of exclusions from Medicare benefits. It is not a legal document.

The official Medicare program provisions are contained in relevant laws, regulations, and rulings.

(January 2003)

Form No. CMS-20007

Notice Of Exclusion Of Medicare Benefits

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