Are you covered by Medicare while traveling within the U.S.?

couple with out children estate planningThose who have reached age 65, the typical age of Medicare eligibility, often have more time to spend traveling.  Although Medicare coverage is generally not available when beneficiaries are overseas, the news may be better for those exploring destinations closer to home.

If you have the original Medicare, the answer is simple: You can travel anywhere in the U.S. or its territories and receive health services from any doctor or hospital that accepts Medicare.  (“Territories” includes Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.) The amount you will pay depends on whether the provider “accepts assignment.”  Providers that take assignment agree to accept the approved Medicare amount as payment in full, although in the case of outpatient visits you or your Medigap insurer may be left with a 20 percent coinsurance, as would be the case for care at home.

Providers that don’t accept assignment may charge you up to 15 percent above the Medicare-approved amount, although this percentage may be lower in some states. In the case of providers that don’t accept Medicare at all, you will have to pay the entire cost of care.

If instead of original Medicare you are in a Medicare Advantage plan (a privately run managed care plan), the answer to the question of coverage is more complicated. Depending on your post-retirement plans, this could be a consideration that affects whether you choose original Medicare or an Advantage plan.

For enrollees traveling for less than six months outside their plan’s service area, Medicare Advantage plans must cover emergency and urgent care.  Charges for such care that is out-of-network cannot exceed $65 or whatever you would have paid for an in-network provider. Whether you will be covered for anything more than emergency or urgent care depends on the plan’s geographic service area, its rules about travel outside of that area and what type of plan it is.

If your plan is of the PPO (Preferred Provider Organization) variety, it must cover care delivered by providers who aren’t in the plan’s network or service area, although you will usually pay more for out-of-network care. Plans that follow the HMO (Health Maintenance Organization) model usually do not cover care from out-of-network providers.  If your HMO plan does cover those providers, be sure to follow the plan’s rules or you may find that you’re not covered.

If you are outside your plan’s service area for six months or more, you will likely be automatically dis-enrolled and returned to original Medicare unless you choose another Medicare Advantage plan.  However, some plans will allow you to travel outside the service area for up to a year. If your plan has such a travel benefit, check what geographic areas and types of care are covered.

For more information on traveling while on a Medicare Advantage plan, check out the Medicare Rights Center website.