Medicare Advantage plan EOC exclusions
When a service is specifically excluded from coverage in a Medicare Evidence of Coverage (EOC) document, you may provide the service IF you:
- Tell the member that their plan's EOC specifically states that the service is not covered.
- Tell the member that he/she will bear 100% of the cost of the service.
- Bill the service with the GY modifier to ensure the claim goes to member liability.
Learn how you or the member can request a pre-service coverage determination (PSOD).
Forms are not required
No form is necessary. Your verbal explanation to the member, documented in the patient's record, is sufficient.
Services excluded from coverage
In addition to the services listed in the table below, services are not covered when:
- The service is not reasonable and medically necessary, according to the standards of Original Medicare. See Chapter 9 of the Evidence of Coverage for how to obtain a coverage decision.
- The service is provided in a Veteran's Affairs (VA) facility
- The service or item is needed due to or related to injuries caused by war or an act of war
- The treatment or service is provided by a person who is not licensed to provide those services, or who is not operating within the scope of that license
|Acupuncture||Not covered under any condition|
|Adaptive equipment||Not covered under any condition|
|Ambulance mileage||Not covered for ambulance transport beyond nearest facility or to/from facility preferred by member and/or family|
|Assistive listening devices||Not covered, including but not limited to telephone amplifiers and alerting devices|
|Bathroom safety devices||Not covered, including but not limited to lifts, raised toilet seats, bidet toilet seats, transfer benches, grab bars, and parallel bars|
|Beds||Not covered, including but not limited to oscillating mattresses, bed baths (home type), bed boards, lifters (elevator), lounges (power or manual)|
|Blood glucose analyzers, reflectance colorimeter type||Not covered under any condition|
|Blood pressure cuff (i.e. pulse tachometer)||Not covered under any condition|
|Chair lift system, chair portion||Not covered under any condition|
|Chiropractic care||Not covered, including but not limited to maintenance care, X-rays, labs, and any other service performed in the office other than services explained in Chapter 4, Section 2.1 of the Medical Benefits Chart in the Evidence of Coverage|
|Concierge care||Not covered under any condition|
|Continuous glucose monitoring (CGM) devices||Only Medicare-approved devices are covered|
|Cosmetic surgery or procedures||Not covered, except for repairs after an accidental injury or to improve a malformed part of the body|
|Counseling services||Not covered, including but not limited to geriatric day care programs, individual psychophysiological therapy including biofeedback, marriage counseling, pastoral counseling and other services not covered by Original Medicare|
|Custodial care||Not covered under any condition|
|Dental services, non-routine, Medicare covered||Dental care required to treat illness or injury may be covered as inpatient or outpatient care. Priority Health will determine if the member meets the medically necessary Medicare criteria.|
|Dental services, routine, not Medicare covered||Not covered: Outpatient facility & professional dental expenses for routine dental services. Limited routine dental services covered under the medical plan are described in Chapter 4, Section 2.1 of the medical benefits chart in the Evidence of Coverage.
For members who purchase the optional Enhanced Vision, Dental, and Hearing supplemental benefit* for an extra premium, additional dental services are covered. See Chapter 4, Section 2.2 of the Evidence of Coverage for details.
|Detox in an outpatient setting||Not covered under any condition|
|Diagnostic lab tests||Not covered unless medically necessary under Medicare coverage criteria|
|Drugs, Part B||Not covered: Non-chemotherapy drugs and biologicals such as biomedical hormones, when used for conditions not approved by Food and Drug Administration (FDA), and not covered under Medicare|
|Drugs, Part D||Not covered when purchased from or obtained while in another country, including those obtained on a cruise ship. These are considered non-FDA approved.
Self-administered drugs may be covered when provided in an outpatient setting such as an outpatient hospital, ER room or physician office.
|Emergency communications systems||Not covered, including personal emergency response systems (PERS), medical alert devices, in-home telephone alert systems|
|Experimental or investigational clinical trials/services||Not covered. See Chapter 3, Section 5.1 of the Evidence of Coverage.|
|FDA exclusions||Services not approved by the Food & Drug Administration are not covered under any condition|
|Fees charged by immediate family/household members||Not covered under any condition|
|Foot care, routine||Some limited coverage provided according to Medicare guidelines (e.g., if you have diabetes)|
|Gender reassignment surgery and gender reassignment hormones||May be covered if determined by Priority Health to meet medical necessity criteria|
|Hearing aid repairs or modifications and/or supplies (batteries)||Not covered under any condition|
|Hearing services, routine, not covered by Medicare||Hearing aid exams, hearing aids and hearing aid evaluations including the fitting and checking of hearing aids may be covered if member has purchased the optional Enhanced Vision, Dental & Hearing supplemental benefit* for an extra premium. See Chapter 4, Section 2.2 of the Evidence of Coverage for details.|
|Homemaker services||Not covered, including but not limited to household assistance, light housekeeping or light meal preparation|
|Homeopathic services||Not covered under any condition|
|Immunizations (when covered under Part D)||Not covered, including but not limited to Zostavax.|
|Incontinence pads/supplies||Not covered under any condition|
|Knee walker||Not covered under any condition|
|Lab tests, routine||Not covered when ordered solely as part of an annual physical exam and not to diagnose a medical condition|
|Long-term care||Not covered under any condition|
|Massage therapy||Not covered when performed by a massage therapist|
|Meals delivered to the home||Not covered under any condition|
|Methadone outpatient clinics||Not covered under any condition|
|Naturopathic services||Not covered under any condition|
|Nursing care, full-time in-home||Not covered under any condition|
|Personal in-room items at a hospital or skilled nursing facility||Not covered, including but not limited to a telephone or television|
|Physical exams and other services required by third parties||Not covered, including but not limited to exams/services for purposes such as obtaining or maintaining employment, participation in employee programs, insurance or licensing, sports participation, on court order, or when required for parole or probation|
|Private-duty nurses||Not covered under any condition
|Private room||Not covered when semi-private rooms are available
|Pre-operative testing||Not covered when performed strictly for pre-operative clearance when no underlying medical condition exists for testing. Including but not limited to lab tests, X-rays, EKGs, EEGs, and cardiac monitoring|
|Residential treatment programs||Not covered when the main purpose is to remove the member from his/her environment to prevent the reoccurrence of a condition such as but not limited to eating disorders, alcohol addiction, etc.|
|Sales tax||Not covered when part of the purchase of medical services and/or items and prescription drugs|
|Smart devices||Not covered, including smart phones, tablets, personal computers, etc. and the cost of applications|
|Sterilization reversal||Not covered under any condition|
|Structural modifications to buildings||Not covered, including but not limited to ramps, doorways, elevators and stairway elevators
|Support hose||Not covered under any condition
|Surgical leggings||Not covered under any condition
|Temporomandibular joint syndrome (TMJ) treatment||Not covered under any condition
|Transportation||Not covered, including commercial or private air transport, car, taxi, bus, gurney van and wheelchair van, even if it is the only way to travel to a network provider|
|Vision services, routine, not covered by Medicare||Not covered, including but not limited to eye exams, eyewear, refraction, retinal imaging, and fitting of eyewear; refractive surgical procedures, laser astigmatism correction, radial keratotomy and keratoplasty to treat refractive defects; LASIK or LASEK surgery; keratophakia and keratomileusis and nonconventional intraocular lenses (IOLs) following cataract surgery (for example, a presbyopia-correcting IOL)
If the member has purchased the optional Enhanced Vision, Dental, and Hearing supplemental benefit* for an extra premium, routine vision services are covered. See Chapter 4, Section 2.2 of the Evidence of Coverage for details.
|Vision, low-vision aids||Not covered under any condition|
|Weight loss treatment||Not covered, including but not limited to medications, self-help groups, non-Medicare covered weight loss programs, meal programs and dietary supplements|
|Wigs||Not covered under any condition|
*Services may be available if the member has purchased the Enhanced Vision, Dental & Hearing package for an extra premium. Benefits are administered through EyeMed, Delta Dental, or Priority Health Medicare for hearing providers. Go to Member Inquiry and use the Supplemental Benefits menu to see if the member has this package.
Evidence of Coverage (EOC)
The Evidence of Coverage is the legal, detailed description of benefits and costs for the plan year. It also explains the rights and rules your client will need to follow when using coverage for medical care and prescription drugs. Download the EOC booklets here.