Does Medicare Cover Weight Loss Surgery?

Top Health Stories

Weight Loss Surgery Costs, Insurance Coverage
Impairment-Related Work Expenses Impairment-related expenses defined. If you receive an amount in settlement of a damage suit for personal injuries, part of that award may be for future medical expenses. Find detailed information on the Roth contribution option here. Imported medicines and drugs. Payments for premiums, non-formulary drugs unless approved by exception or appeal , drugs purchased outside the US, and drugs paid for by other insurance do not count toward TrOOP. In figuring your medical expense deduction, you can include only one-fourth of your mother's medical expenses.

Password Reset

You don't join us, we join you

There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to: Loss Irreparable damage, or Change in medical condition e. A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form. Cervical Traction Cervical traction devices are covered only if both of the criteria below are met: You have a musculoskeletal or neurologic impairment requiring traction equipment.

The appropriate use of a home cervical traction device has been demonstrated to you and you are able to tolerate the selected device. You are confined to a single room, or You are confined to one level of the home environment and there is no toilet on that level, or You are confined to the home and there are no toilet facilities in the home. Heavy-duty commodes are covered if you weigh over pounds. Commodes with detachable arms are covered if your body configuration requires extra width, or if the arms are needed to transfer in and out of the chair.

Raised toilet seats that are used to position hand bars over a regular toilet are not covered by Medicare. Compression Stockings Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers.

They are not reimbursed by Medicare for the prevention of ulcers, prevention of the reoccurrence of ulcers, treatment of lymphedema or swelling without ulcers. Medicare requires that you first meet with your physician or healthcare provider to discuss your symptoms and risk factors for Obstructive Sleep Apnea.

After meeting with your doctor or healthcare provider, you must then have an overnight sleep study performed in a sleep laboratory or through a special, in-home sleep test to establish a qualifying diagnosis of Obstructive Sleep Apnea. Your doctor or healthcare provider may then prescribe a CPAP to treat your obstructive sleep apnea.

Medicare will initially cover a three month trial of this equipment. Medicare will also pay for replacement masks, tubing and other necessary supplies as prescribed by your doctor or healthcare provider.

If during your sleep study or during your trial period the CPAP device is not working for you, or if you cannot tolerate the CPAP machine, your doctor or healthcare provider may prescribe a different device called a Bi-Level or a Respiratory Assist Device, and Medicare can consider this for coverage as well. After the first three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine.

Per Medicare, a follow-up face-to-face visit with your physician or healthcare provider is required to document an improvement of your symptoms no sooner than 31 days and no later than 91 days from the set-up date.

Talk with your supplier if you are having problems adjusting to the therapy or using the equipment every night. There are a lot of variations that can make the therapy more comfortable for you. CPAPs and Bi-Levels are considered capped rental items, and that means they cannot be purchased outright.

Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.

Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a written order or certificate of medical necessity from your doctor or healthcare provider. When at home, you may receive up to a 3-month supply at one time. You must have nearly depleted the supplies on hand to be eligible for additional products. Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan. Diabetics can obtain up to a three month supply of testing materials at a time.

Medicare will approve up to one test per day for non-insulin dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification of need. If you test above these guidelines, you are required to be seen and evaluated by your physician or healthcare provider within six months prior to receiving your initial supplies from your supplier. In addition, you must send your supplier evidence of compliant testing e.

If at any time your testing frequency changes, your physician or healthcare provider will need to give your supplier a new prescription. Medicare began a namail - orderl order program in July of that requires you to get your diabetic supplies through one of approximately 20, nationally contracted suppliers for all testing supplies delivered to your home. Your supplier may not be able to deliver your glucometer to you without a written order or certificate of medical necessity from your doctor or healthcare provider.

Glasses Medicare covers one complete pair of glasses, after the last cataract surgery with intra-ocular lens replacement. The Medicare benefit includes a frame and two lenses. As an alternative, a pair of contact lenses can be covered in lieu of glasses. Pillows or wedges must have been considered and ruled out, or You require traction equipment which can only be attached to a hospital bed. Specialty beds that allow the height of the bed to be adjusted are covered if you require this feature to permit transfers to a chair, wheelchair or standing position.

The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, your supplier usually can apply the cost of the qualifying hospital bed toward the monthly rental price of the total electric model.

You will need to sign an Advance Beneficiary Notice ABN and will be responsible to pay the difference in the retail charges between the two items every month.

Hospital beds are a capped rental item, and that means they cannot be purchased outright. Lymphedema Pumps Compression Pumps are not reimbursed by Medicare for the treatment of peripheral artery disease or the prevention of venous thrombosis blood clots. Lymphedema Pumps are covered for treatment of true lymphedema as a result of: This is a relatively uncommon, chronic condition , or Secondary lymphedema which is much more common and results from the destruction of or damage to formerly functioning lymphatic channels that may result from: The incidence of lymphedema from CVI is not well established.

However, Medicare has established guidelines for CVI with one or more venous stasis ulcers. When lymphedema extends into the chest, trunk or abdomen, a specialty pump can be considered. Before you can be prescribed a pump, your physician or healthcare provider must monitor you during a minimum, four-week trial period for lymphedema and six week trial for CVI with ulcers.

During the trial your doctor or healthcare provider must document the results of other treatment options including limb elevation, regular exercise, compression bandage systems or compression garments, dietary adjustments, and the use of diuretic and similar medications as applicable.

Your doctor or healthcare provider should document pre and post measurements in your chart notes as each conservative treatment is evaluated. If, during the trial there is any improvement using these other methods, Medicare will not approve a pump.

Medicare will only consider reimbursing for the pump when you have been unresponsive to the conservative treatment and there is no significant improvement over the required trial period the most recent four or six weeks. Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider.

Medicare-covered drugs other than Medicare Part D coverage All suppliers of Medicare-covered drugs are required to accept assignment on these items. Very few medications are covered under your Part B benefit. Traditional Medicare Part B insurance will cover some nebulizer drugs, some infused drugs that require the use of a pump, specific immunosuppressive drugs, select oral anti-cancer medications and most parenteral nutrition.

The Medicare Part D plans may provide additional coverage of other oral medications, inhalers and similar drugs. Mobility needs for daily activities within the home The lowest level of equipment required to accomplish these tasks. The most medically appropriate equipment that meets your needs, not your wants Medicare requires that your physician or healthcare provider and supplier evaluate your needs and expected use of the mobility product to determine which item you will qualify for.

They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions: Will a cane or crutches allow you to perform these activities in the home?

If not, will a walker allow you to accomplish these activities in the home? If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home? If not, will a scooter allow you to accomplish these activities in the home?

If not, will a power chair allow you to accomplish these activities in the home? Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your supplier the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice ABN. Your home must be evaluated to ensure it will accommodate the use of any mobility product.

A face-to-face examination with your physician or healthcare provider to specifically discuss your mobility limitations and need for mobility is required prior to the initial setup of a power chair, scooter or manual wheelchair.

In some cases for custom manual chairs and power mobility items you may also be asked to see a physical therapist or occupational therapist to determine the best fit and equipment selection. The majority of all manual and power wheelchairs are considered capped rental items, and that means they cannot be purchased outright.

If at any time you stop using your medications, please notify your supplier. Nebulizer machines are considered to be capped rental items, and that means they cannot be purchased outright.

When at home, you may receive up to a 3-month supply of nebulizer accessories at one time. Non-covered items partial listing: Medicare will only pay for the shoe s attached to the leg brace s. Medicare will not pay for matching shoes or for shoes that are needed for purposes other than for diabetes or leg braces. Ostomy Supplies Ostomy supplies are covered for people with a: If your symptoms are indicative of a chronic lung condition or other disease that requires long term oxygen therapy, Medicare will likely cover oxygen when the test results meet the coverage criteria outlined below.

Oxygen is not covered for acute illnesses like pneumonia or for exacerbations of an underlying disease, because this is considered a temporary, acute or unstable condition. Oxygen is covered if you have significant hypoxemia in a chronic stable state when: You have a severe lung disease or hypoxemia that might be expected to improve with oxygen therapy, and Your blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and Your oxygen study was performed by a physician, qualified lab, other qualified provider and Alternative treatments have been tried or deemed clinically ineffective.

There are two types of tests that can be used for this purpose. An Arterial Blood Gas ABG test is an invasive procedure which provides detailed information and a direct measurement of oxygen in arterial blood from an artery. ABG test results are reported in millimeters of mercury mmHg. A saturation test SAT is a non-invasive procedure that indirectly measures oxygen saturation using a sensor typically placed on the ear or finger. Typically, you will not have to be retested when you return to your physician or healthcare provider for the follow-up visit.

Note on nocturnal oxygen therapy: If you only require the use of oxygen during the nighttime, your doctor should rule out obstructive sleep apnea as a cause for the hypoxemia symptoms you may be experiencing. If obstructive sleep apnea is a potential factor, Medicare will not cover oxygen therapy until you have officially had the sleep apnea diagnosed and treated.

When obstructive sleep apnea is a factor, testing for oxygen can only begin after the apneas are controlled with appropriate positive airway therapy using a CPAP or Bi-PAP. When obstructive sleep apnea is a factor, you can only be tested in a facility not in your home. Oxygen will be paid as a rental for the first 36 months. After that time, if you still need the equipment, Medicare will no longer make rental payments on the equipment.

However, if equipment is still necessary, your supplier will continue to provide the equipment to you for an additional 24 months. During this two year service period, Medicare will pay your supplier for refilling your oxygen cylinders if you have gas or liquid systems and for a semi-annual maintenance fee.

After 60 months of service through Medicare your supplier is not obligated to continue service, but you may choose to receive new equipment and Medicare will begin paying for your equipment rental again. Depending on which product is ordered, your supplier may not be able deliver this equipment to you without a written order or certificate of medical necessity from your doctor or healthcare provider. Nutritional formulas are delivered through a vein.

Enteral therapy is covered if you cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract. Medicare will not pay for nutritional formulas that are taken orally. In most cases you may have to try standard formulas and document that they are unsuccessful before Medicare will consider the specialty nutrition. You must have nearly depleted the supplies on hand to be eligible for additional product.

An electric lift mechanism is not covered; because it is considered a convenience feature. If you prefer to have the electric mechanism, your supplier can usually apply the cost of the manual lift toward the purchase price of the electric model. You will need to sign an Advance Beneficiary Notice ABN and would be responsible to pay the difference in the retail charges between the two items on a monthly basis.

Patient lifts are considered to be capped rental items, and that means they cannot be purchased outright. Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider. In addition you must be completely incapable of standing up from any chair, but once standing can walk either independently or with the aid of a walker or cane. The physician or healthcare provider must believe that the mechanism will improve, slow down or stop the deterioration of your condition.

Transferring directly into a wheelchair will prevent Medicare from paying for the device. Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.

Your supplier cannot deliver this equipment to you without a written order or certificate of medical necessity from your doctor or healthcare provider. To include these expenses, you must have been married either at the time your spouse received the medical services or at the time you paid the medical expenses.

Mary received medical treatment before she married Bill. Bill paid for the treatment after they married. Bill can include these expenses in figuring his medical expense deduction even if Bill and Mary file separate returns. If Mary had paid the expenses, Bill couldn't include Mary's expenses in his separate return. Mary would include the amounts she paid during the year in her separate return. If they filed a joint return, the medical expenses both paid during the year would be used to figure their medical expense deduction.

This year, John paid medical expenses for his wife Louise, who died last year. John married Belle this year and they file a joint return. Because John was married to Louise when she received the medical services, he can include those expenses in figuring his medical expense deduction for this year. You can include medical expenses you paid for your dependent.

For you to include these expenses, the person must have been your dependent either at the time the medical services were provided or at the time you paid the expenses.

A person generally qualifies as your dependent for purposes of the medical expense deduction if both of the following requirements are met. The person was a qualifying child defined later or a qualifying relative defined later , and.

The person was a U. If your qualifying child was adopted, see Exception for adopted child , later. You can include medical expenses you paid for an individual that would have been your dependent except that:. You, or your spouse if filing jointly, could be claimed as a dependent on someone else's return. If you are a U. Is your son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, half brother, half sister, or a descendant of any of them for example, your grandchild, niece, or nephew ,.

Under age 24 at the end of , a full-time student, and younger than you or your spouse, if filing jointly , or. A legally adopted child is treated as your own child. This child includes a child lawfully placed with you for legal adoption. You can include medical expenses that you paid for a child before adoption if the child qualified as your dependent when the medical services were provided or when the expenses were paid. If you pay back an adoption agency or other persons for medical expenses they paid under an agreement with you, you are treated as having paid those expenses provided you clearly substantiate that the payment is directly attributable to the medical care of the child.

But if you pay the agency or other person for medical care that was provided and paid for before adoption negotiations began, you can't include them as medical expenses. You may be able to take a credit for other expenses related to an adoption. For purposes of the medical and dental expenses deduction, a child of divorced or separated parents can be treated as a dependent of both parents. Each parent can include the medical expenses he or she pays for the child, even if the other parent claims the child's dependency exemption, if: The child is in the custody of one or both parents for more than half the year,.

The child receives over half of his or her support during the year from his or her parents, and. Are divorced or legally separated under a decree of divorce or separate maintenance,.

This doesn't apply if the child's exemption is being claimed under a multiple support agreement discussed later. Son, daughter, stepchild, or foster child, or a descendant of any of them for example, your grandchild ,. Father, mother, or an ancestor or sibling of either of them for example, your grandmother, grandfather, aunt, or uncle ,. Stepbrother, stepsister, stepfather, stepmother, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law, or.

Any other person other than your spouse who lived with you all year as a member of your household if your relationship didn't violate local law,. Who wasn't a qualifying child see Qualifying Child , earlier of any taxpayer for , and. For whom you provided over half of the support in But see Child of divorced or separated parents , earlier, Support claimed under a multiple support agreement , next, and Kidnapped child under Qualifying Relative in Pub. If you are considered to have provided more than half of a qualifying relative's support under a multiple support agreement, you can include medical expenses you pay for that person.

A multiple support agreement is used when two or more people provide more than half of a person's support, but no one alone provides more than half. Any medical expenses paid by others who joined you in the agreement can't be included as medical expenses by anyone. However, you can include the entire unreimbursed amount you paid for medical expenses. You and your three brothers each provide one-fourth of your mother's total support.

Under a multiple support agreement, you treat your mother as your dependent. You paid all of her medical expenses. Your brothers repaid you for three-fourths of these expenses. In figuring your medical expense deduction, you can include only one-fourth of your mother's medical expenses. Your brothers can't include any part of the expenses. However, if you and your brothers share the nonmedical support items and you separately pay all of your mother's medical expenses, you can include the unreimbursed amount you paid for her medical expenses in your medical expenses.

Medical expenses paid before death by the decedent are included in figuring any deduction for medical and dental expenses on the decedent's final income tax return. This includes expenses for the decedent's spouse and dependents as well as for the decedent.

The survivor or personal representative of a decedent can choose to treat certain expenses paid by the decedent's estate for the decedent's medical care as paid by the decedent at the time the medical services were provided. The expenses must be paid within the 1-year period beginning with the day after the date of death.

If you are the survivor or personal representative making this choice, you must attach a statement to the decedent's Form or the decedent's amended return, Form X saying that the expenses haven't been and won't be claimed on the estate tax return.

Qualified medical expenses paid before death by the decedent aren't deductible if paid with a tax-free distribution from any Archer MSA, Medicare Advantage MSA, or health savings account. What if the decedent's return had been filed and the medical expenses weren't included?

Form X can be filed for the year or years the expenses are treated as paid, unless the period for filing an amended return for that year has passed.

Generally, an amended return must be filed within 3 years of the date the original return was filed, or within 2 years from the time the tax was paid, whichever date is later.

John properly filed his income tax return. What if you pay medical expenses of a deceased spouse or dependent? If you paid medical expenses for your deceased spouse or dependent, include them as medical expenses on your Schedule A Form in the year paid, whether they are paid before or after the decedent's death. The expenses can be included if the person was your spouse or dependent either at the time the medical services were provided or at the time you paid the expenses.

Following is a list of items that you can include in figuring your medical expense deduction. The items are listed in alphabetical order. This list doesn't include all possible medical expenses.

To determine if an expense not listed can be included in figuring your medical expense deduction, see What Are Medical Expenses , earlier. You can include in medical expenses amounts you pay for an inpatient's treatment at a therapeutic center for alcohol addiction.

This includes meals and lodging provided by the center during treatment. You can also include in medical expenses amounts you pay for transportation to and from Alcoholics Anonymous meetings in your community if the attendance is pursuant to medical advice that membership in Alcoholics Anonymous is necessary for the treatment of a disease involving the excessive use of alcoholic liquors. See Physical Examination , later. You can include in medical expenses the amount you pay for birth control pills prescribed by a doctor.

You can include in medical expenses the part of the cost of Braille books and magazines for use by a visually impaired person that is more than the cost of regular printed editions. You can include in medical expenses the amounts you pay for breast reconstruction surgery, as well as breast prosthesis, following a mastectomy for cancer. See Cosmetic Surgery , later. You can include in medical expenses amounts you pay for special equipment installed in a home, or for improvements, if their main purpose is medical care for you, your spouse, or your dependent.

The cost of permanent improvements that increase the value of your property may be partly included as a medical expense. The cost of the improvement is reduced by the increase in the value of your property. The difference is a medical expense. If the value of your property isn't increased by the improvement, the entire cost is included as a medical expense. Certain improvements made to accommodate a home to your disabled condition, or that of your spouse or your dependents who live with you, don't usually increase the value of the home and the cost can be included in full as medical expenses.

These improvements include, but aren't limited to, the following items. Installing porch lifts and other forms of lifts but elevators generally add value to the house.

Only reasonable costs to accommodate a home to a disabled condition are considered medical care. Additional costs for personal motives, such as for architectural or aesthetic reasons, aren't medical expenses.

Use Worksheet A to figure the amount of your capital expense to include in your medical expenses. Amounts you pay for operation and upkeep of a capital asset qualify as medical expenses, as long as the main reason for them is medical care.

This rule applies even if none or only part of the original cost of the capital asset qualified as a medical care expense. Amounts paid to buy and install special plumbing fixtures for a person with a disability, mainly for medical reasons, in a rented house are medical expenses. John has arthritis and a heart condition.

He can't climb stairs or get into a bathtub. On his doctor's advice, he installs a bathroom with a shower stall on the first floor of his two-story rented house. The landlord didn't pay any of the cost of buying and installing the special plumbing and didn't lower the rent. John can include in medical expenses the entire amount he paid.

You can include in medical expenses the cost of special hand controls and other special equipment installed in a car for the use of a person with a disability. You can include in medical expenses the difference between the cost of a regular car and a car specially designed to hold a wheelchair.

The includible costs of using a car for medical reasons are explained under Transportation , later. You can include in medical expenses fees you pay to Christian Science practitioners for medical care. You can include in medical expenses amounts you pay for contact lenses needed for medical reasons. You can also include the cost of equipment and materials required for using contact lenses, such as saline solution and enzyme cleaner. See Eyeglasses and Eye Surgery , later.

You can include in medical expenses the amounts you pay for the prevention and alleviation of dental disease. Preventive treatment includes the services of a dental hygienist or dentist for such procedures as teeth cleaning, the application of sealants, and fluoride treatments to prevent tooth decay. Treatment to alleviate dental disease includes services of a dentist for procedures such as X-rays, fillings, braces, extractions, dentures, and other dental ailments.

You can include in medical expenses the cost of devices used in diagnosing and treating illness and disease. You have diabetes and use a blood sugar test kit to monitor your blood sugar level. You can include the cost of the blood sugar test kit in your medical expenses. You can choose to apply them either way as long as you don't use the same expenses to claim both a credit and a medical expense deduction. You can include in medical expenses amounts you pay for an inpatient's treatment at a therapeutic center for drug addiction.

This includes meals and lodging at the center during treatment. See Medicines , later. You can include in medical expenses amounts you pay for eyeglasses and contact lenses needed for medical reasons. See Contact Lenses , earlier, for more information. You can include in medical expenses the amount you pay for eye surgery to treat defective vision, such as laser eye surgery or radial keratotomy. You can include in medical expenses the cost of the following procedures to overcome an inability to have children.

Procedures such as in vitro fertilization including temporary storage of eggs or sperm. Surgery, including an operation to reverse prior surgery that prevented the person operated on from having children. See Lifetime Care—Advance Payments , later. You can include in medical expenses the costs of buying, training, and maintaining a guide dog or other service animal to assist a visually impaired or hearing disabled person, or a person with other physical disabilities.

In general, this includes any costs, such as food, grooming, and veterinary care, incurred in maintaining the health and vitality of the service animal so that it may perform its duties.

You can include in medical expenses fees you pay for treatment at a health institute only if the treatment is prescribed by a physician and the physician issues a statement that the treatment is necessary to alleviate a physical or mental disability or illness of the individual receiving the treatment. You can include in medical expenses amounts you pay to entitle you, your spouse, or a dependent to receive medical care from an HMO.

These amounts are treated as medical insurance premiums. See Insurance Premiums , later. You can include in medical expenses the cost of a hearing aid and batteries, repairs, and maintenance needed to operate it. See Nursing Services , later. See Capital Expenses , earlier. You can include in medical expenses amounts you pay for the cost of inpatient care at a hospital or similar institution if a principal reason for being there is to receive medical care. This includes amounts paid for meals and lodging.

Also see Lodging , later. You can include in medical expenses insurance premiums you pay for policies that cover medical care. You can't include in medical expenses insurance premiums that were paid and for which you are claiming a credit or deduction. Medical care policies can provide payment for treatment that includes:. Long-term care subject to additional limitations. If you have a policy that provides payments for other than medical care, you can include the premiums for the medical care part of the policy if the charge for the medical part is reasonable.

The cost of the medical part must be separately stated in the insurance contract or given to you in a separate statement. When figuring the amount of insurance premiums you can deduct on Schedule A, don't include any of the following. Any qualified health insurance coverage premiums you paid to "U. Treasury—HCTC" for eligible coverage months for which you received the benefit of the advance monthly payment program, or. If advance payments of the premium tax credit were made or you are eligible for both the premium tax credit and the HCTC and elect to take the HCTC, see the Instructions for Form to see how to figure your credit.

Don't include in your medical and dental expenses any insurance premiums paid by an employer-sponsored health insurance plan unless the premiums are included on your Form W-2, Wage and Tax Statement.

Also, don't include any other medical and dental expenses paid by the plan unless the amount paid is included on your Form W Your share of the FEHB premium is paid by making a pre-tax reduction in your salary. Because you are an employee whose insurance premiums are paid with money that is never included in your gross income, you can't deduct the premiums paid with that money.

Contributions made by your employer to provide coverage for qualified long-term care services under a flexible spending or similar arrangement must be included in your income. This amount will be reported as wages on your Form W If you are a retired public safety officer, don't include as medical expenses any health or long-term care insurance premiums that you elected to have paid with tax-free distributions from a retirement plan.

This applies only to distributions that would otherwise be included in income. If you have medical expenses that are reimbursed by a health reimbursement arrangement, you can't include those expenses in your medical expenses. This is because an HRA is funded solely by the employer. If you are covered under social security or if you are a government employee who paid Medicare tax , you are enrolled in Medicare A.

The payroll tax paid for Medicare A isn't a medical expense. If you aren't covered under social security or weren't a government employee who paid Medicare tax , you can voluntarily enroll in Medicare A. In this situation you can include the premiums you paid for Medicare A as a medical expense. Medicare B is a supplemental medical insurance. Premiums you pay for Medicare B are a medical expense.

Check the information you received from the Social Security Administration to find out your premium. Medicare D is a voluntary prescription drug insurance program for persons with Medicare A or B. You can include as a medical expense premiums you pay for Medicare D.

Premiums you pay before you are age 65 for insurance for medical care for yourself, your spouse, or your dependents after you reach age 65 are medical care expenses in the year paid if they are:. You must include in gross income cash payments you receive at the time of retirement for unused sick leave.

You also must include in gross income the value of unused sick leave that, at your option, your employer applies to the cost of your continuing participation in your employer's health plan after you retire. You can include this cost of continuing participation in the health plan as a medical expense.

If you participate in a health plan where your employer automatically applies the value of unused sick leave to the cost of your continuing participation in the health plan and you don't have the option to receive cash , don't include the value of the unused sick leave in gross income.

You can't include this cost of continuing participation in that health plan as a medical expense. Policies that pay you a guaranteed amount each week for a stated number of weeks if you are hospitalized for sickness or injury,. The part of your car insurance that provides medical insurance coverage for all persons injured in or by your car because the part of the premium providing insurance for you, your spouse, and your dependents isn't stated separately from the part of the premium providing insurance for medical care for others, or.

Health or long-term care insurance if you elected to pay these premiums with tax-free distributions from a retirement plan made directly to the insurance provider and these distributions would otherwise have been included in income. Generally, you can't deduct any additional premium you pay as the result of including on your policy someone who isn't your spouse or dependent, even if that person is your child under age However, you can deduct the additional premium if that person is: Your child whom you don't claim as a dependent because of the rules for children of divorced or separated parents,.

Any person you could have claimed as a dependent except that you, or your spouse if filing jointly, can be claimed as a dependent on someone else's return. Also, if you had family coverage when you added this individual to your policy and your premiums didn't increase, you can enter on Schedule A Form the full amount of your medical and dental insurance premiums.

You can include in medical expenses the cost of keeping a person who is intellectually and developmentally disabled in a special home, not the home of a relative, on the recommendation of a psychiatrist to help the person adjust from life in a mental hospital to community living.

You can include in medical expenses the amounts you pay for laboratory fees that are part of medical care. See Breast Pumps and Supplies , earlier.

You can include in medical expenses the cost of removing lead-based paints from surfaces in your home to prevent a child who has or had lead poisoning from eating the paint.

These surfaces must be in poor repair peeling or cracking or within the child's reach. The cost of repainting the scraped area isn't a medical expense. If, instead of removing the paint, you cover the area with wallboard or paneling, treat these items as capital expenses.

Don't include the cost of painting the wallboard as a medical expense. See Special Education , later. You can include in medical expenses legal fees you paid that are necessary to authorize treatment for mental illness. However, you can't include in medical expenses fees for the management of a guardianship estate, fees for conducting the affairs of the person being treated, or other fees that aren't necessary for medical care.

You can include in medical expenses a part of a life-care fee or "founder's fee" you pay either monthly or as a lump sum under an agreement with a retirement home.

The part of the payment you include is the amount properly allocable to medical care. The agreement must require that you pay a specific fee as a condition for the home's promise to provide lifetime care that includes medical care.

You can use a statement from the retirement home to prove the amount properly allocable to medical care. The statement must be based either on the home's prior experience or on information from a comparable home. You can include in medical expenses advance payments to a private institution for lifetime care, treatment, and training of your physically or mentally impaired child upon your death or when you become unable to provide care.

The payments must be a condition for the institution's future acceptance of your child and must not be refundable. Generally, you can't include in medical expenses current payments for medical care including medical insurance to be provided substantially beyond the end of the year. This rule doesn't apply in situations where the future care is purchased in connection with obtaining lifetime care of the type described earlier. You can include in medical expenses the cost of meals and lodging at a hospital or similar institution if a principal reason for being there is to receive medical care.

See Nursing Home , later. You may be able to include in medical expenses the cost of lodging not provided in a hospital or similar institution. You can include the cost of such lodging while away from home if all of the following requirements are met.

The medical care is provided by a doctor in a licensed hospital or in a medical care facility related to, or the equivalent of, a licensed hospital. There is no significant element of personal pleasure, recreation, or vacation in the travel away from home. You can include lodging for a person traveling with the person receiving the medical care. Don't include the cost of lodging while away from home for medical treatment if that treatment isn't received from a doctor in a licensed hospital or in a medical care facility related to, or the equivalent of, a licensed hospital or if that lodging isn't primarily for or essential to the medical care received.

You can include in medical expenses amounts paid for qualified long-term care services and premiums paid for qualified long-term care insurance contracts. Qualified long-term care services are necessary diagnostic, preventive, therapeutic, curing, treating, mitigating, rehabilitative services, and maintenance and personal care services defined later that are:.

An individual is chronically ill if, within the previous 12 months, a licensed health care practitioner has certified that the individual meets either of the following descriptions.

He or she is unable to perform at least two activities of daily living without substantial assistance from another individual for at least 90 days, due to a loss of functional capacity. Activities of daily living are eating, toileting, transferring, bathing, dressing, and continence. He or she requires substantial supervision to be protected from threats to health and safety due to severe cognitive impairment. Maintenance or personal care services is care which has as its primary purpose the providing of a chronically ill individual with needed assistance with his or her disabilities including protection from threats to health and safety due to severe cognitive impairment.

A qualified long-term care insurance contract is an insurance contract that provides only coverage of qualified long-term care services. Not provide for a cash surrender value or other money that can be paid, assigned, pledged, or borrowed,. Provide that refunds, other than refunds on the death of the insured or complete surrender or cancellation of the contract, and dividends under the contract must be used only to reduce future premiums or increase future benefits, and.

Generally not pay or reimburse expenses incurred for services or items that would be reimbursed under Medicare, except where Medicare is a secondary payer, or the contract makes per diem or other periodic payments without regard to expenses. The amount of qualified long-term care premiums you can include is limited.

You can include the following as medical expenses on Schedule A Form Also, if you are an eligible retired public safety officer, you can't include premiums for long-term care insurance if you elected to pay these premiums with tax-free distributions from a qualified retirement plan made directly to the insurance provider and these distributions would otherwise have been included in your income.

You can include in medical expenses the cost of meals at a hospital or similar institution if a principal reason for being there is to get medical care. You can't include in medical expenses the cost of meals that aren't part of inpatient care. You can include in medical expenses amounts paid for admission and transportation to a medical conference if the medical conference concerns the chronic illness of yourself, your spouse, or your dependent. The costs of the medical conference must be primarily for and necessary to the medical care of you, your spouse, or your dependent.

The majority of the time spent at the conference must be spent attending sessions on medical information. The cost of meals and lodging while attending the conference isn't deductible as a medical expense. You can include in medical expenses amounts paid to a plan that keeps medical information in a computer data bank and retrieves and furnishes the information upon request to an attending physician.

You can include in medical expenses amounts you pay for prescribed medicines and drugs. A prescribed drug is one that requires a prescription by a doctor for its use by an individual.

You can also include amounts you pay for insulin. Except for insulin, you can't include in medical expenses amounts you pay for a drug that isn't prescribed. You can include in medical expenses the cost of medical care in a nursing home, home for the aged, or similar institution, for yourself, your spouse, or your dependents.

This includes the cost of meals and lodging in the home if a principal reason for being there is to get medical care. Don't include the cost of meals and lodging if the reason for being in the home is personal. You can, however, include in medical expenses the part of the cost that is for medical or nursing care. You can include in medical expenses wages and other amounts you pay for nursing services.

The services need not be performed by a nurse as long as the services are of a kind generally performed by a nurse. This includes services connected with caring for the patient's condition, such as giving medication or changing dressings, as well as bathing and grooming the patient.

These services can be provided in your home or another care facility. Generally, only the amount spent for nursing services is a medical expense. If the attendant also provides personal and household services, amounts paid to the attendant must be divided between the time spent performing household and personal services and the time spent for nursing services. However, certain maintenance or personal care services provided for qualified long-term care can be included in medical expenses. See Maintenance and personal care services under Long-Term Care , earlier.

Additionally, certain expenses for household services or for the care of a qualifying individual incurred to allow you to work may qualify for the child and dependent care credit. You can also include in medical expenses part of the amount you pay for that attendant's meals.

Divide the food expense among the household members to find the cost of the attendant's food. Then divide that cost in the same manner as in the preceding paragraph. If you had to pay additional amounts for household upkeep because of the attendant, you can include the extra amounts with your medical expenses.

This includes extra rent or utilities you pay because you moved to a larger apartment to provide space for the attendant. You can include as a medical expense social security tax, FUTA, Medicare tax, and state employment taxes you pay for an attendant who provides medical care.

If the attendant also provides personal and household services, you can include as a medical expense only the amount of employment taxes paid for medical services as explained earlier. For information on employment tax responsibilities of household employers, see Pub. You can include in medical expenses amounts you pay for legal operations that aren't for unnecessary cosmetic surgery. See Eyeglasses , earlier.

See Transplants , later. You can include in medical expenses amounts you pay for oxygen and oxygen equipment to relieve breathing problems caused by a medical condition. You can include in medical expenses the amount you pay for an annual physical examination and diagnostic tests by a physician. You don't have to be ill at the time of the examination. You can include in medical expenses the amount you pay to purchase a pregnancy test kit to determine if you are pregnant.

You can't include in medical expenses the amount of health insurance premiums paid by or through the premium tax credit. You also can't include in medical expenses any amount of advance payments of the premium tax credit made that you did not have to pay back. In fact, the pharmacy may substitute a generic drug for a brand name drug at the point of sale because these formulary changes fall into the category of maintenance changes, which do not require advance notice to the beneficiary.

There is no transition policy that guarantees a member the right to continue to receive the brand name drug for the rest of the year when a generic becomes available. Members need to read their EOC's Evidence of Coverage carefully to find out what they need to do to get brand name drugs instead of generics.

Usually, it is necessary to file an exception or appeal request. To prevail in an exception or appeal, the physician must document a history of adverse reactions or ineffectiveness of the generic. All Part D sponsors must have a transition process to ensure that newly enrolled members, and other individuals described below, have access to non-formulary medications during their first 90 days in a plan. For transition purposes, formulary drugs that are subject to prior authorization or step therapy are treated as non-formulary drugs.

The plan must provide a written notice to all members who receive a transition fill within three business days of the temporary fill. For members living in the community, the temporary supply is a one-time fill for at least 30 days of medication unless the script is written for fewer days. For members living in long-term care facilities, the temporary supply may be for up to 31 days, and may be renewed as necessary during the entire length of the day transition period.

Depending upon the circumstances of the individual, the transition period may be extended beyond the day period. At a minimum, plan sponsors must offer a "standard benefit" package mandated by law. The standard benefit includes an annual deductible and a gap in coverage known as the "Donut Hole.

Finally, they may also offer "enhanced" plans that provide benefits in addition to the standard benefit. Typically, the enhanced plans offer some coverage during the Donut Hole. The Standard Benefit is defined in terms of the benefit structure, not the drugs that must be covered under the plan. This is called the Deductible Phase, or Stage 1.

This is called the Initial Coverage Period or Stage 2. The process begins over again the next year. Medicare does not establish premium amounts for plans. Instead, premiums are established through an annual competitive bidding process and evaluated by CMS. The table below shows the standard benefit each year from — Standard Part D Benefit Starting in prices are discounted, see below. Begins when member NOT plan has spent a total of….

Cost sharing during Catastrophic Coverage. Most plans do not follow the defined Standard Benefit DS model. Medicare law allows plans to offer actuarially equivalent or enhanced plans. While structured differently, these alternative plans cannot impose a higher deductible or higher initial coverage limits or out-of-pocket thresholds. The value of benefits in an actuarially equivalent plan must be at least as valuable as the Standard Benefit.

Actuarially Equivalent AE plans — have the same deductible as the standard benefit but have different cost-sharing. Basic Alternative BA plans — have a smaller deductible, with or without different cost sharing, such as tiered cost sharing. Most typically, they include coverage of some drugs during the Donut Hole. Medicare Part D beneficiaries with higher incomes pay higher Medicare Part D premiums based on their income, similar to higher Part B premiums already paid by this group.

The IRMAA is withheld from an individual's monthly Social Security payment, even if the beneficiary otherwise makes premium payments directly to the plan. In a tiered model, various drugs are assigned to different drug tiers and will cost more or less than other drugs depending upon their tier placement.

Cost sharing in various tiers may take the form of co-pays a flat dollar amount , or co-insurance a percentage of costs. When Part D began in , drug tiers were fairly straightforward. For example, cost sharing might appear as follows:. Specialty drugs and injectables. Since , however, plans have taken advantage of their ability to define their own tiers.

Some plans have four tiers while others now have five or even six. The placement of drugs within tiers also varies among plans. For example, the same generic may be a Tier 1 drug in one plan, a Tier 2 drug in another plan, and a Tier 3 drug in yet another plan. Adding to the confusion, some plans make tier distinctions between "value" and "regular" generics, and may further classify and price accordingly "value," "preferred," and "non-preferred" brand name and generic drugs.

While the Plan Finder is relatively easy to use, Medicare beneficiaries who lack confidence in their computer skills should ask family, friends, their local pharmacy, or their area SHIP agency to help them compare plans on the Plan Finder.

While a few plans offer coverage of drugs during the Donut Hole, such coverage is generally limited to generics. Few plans cover brand name drugs during this period.

Further, co-pays for drugs covered during the Donut Hole may be higher than they are in the Initial Coverage Period. Once beneficiaries reach their out-of pocket threshold their "true out-of-pocket" TrOOP costs , they move out of the Donut Hole and into Catastrophic Coverage. Payments for premiums, non-formulary drugs unless approved by exception or appeal , drugs purchased outside the US, and drugs paid for by other insurance do not count toward TrOOP.

Therefore, in order to get credit for their drug costs during the Donut Hole, it is imperative that members use plan network pharmacies and show the pharmacy their plan membership card. Plans are required to send their members an Explanation of Benefits EOB for every month that the member uses plan services. The EOB shows what the member, the plan, and others paid for drugs during the period.

For some individuals, drug costs during the Donut Hole present an extreme financial hardship. In some cases, a single medication may costs hundreds, even thousands, of dollars.

Paying for such an expensive drug during the Donut Hole will help move the member toward eligibility for Catastrophic Coverage. However, coming up with this amount of money all at once — even for a critical medication — may be impossible for some people. This not-uncommon scenario means that some people simply do not take their medications during the Donut Hole.

There are programs to help people with their Part D costs, including some that provide coverage during the Donut Hole. Other sources of help include pharmacy discount cards, drug manufacturer Patient Assistance Programs PAPs , and insurance company discount programs. For a complete listing of many drug assistance programs see our article " Finding Help to Get Prescription Drugs.

The Donut Hole will gradually be phased out between and In subsequent years, gradually increasing discounts will be applied to brand name and generic drugs. Donut Hole Drug Discounts by Year, The discounts will be given right at the pharmacy — members will not have to fill out forms or do anything to get the discount.

Members will have to pay a small dispensing fee cost to the pharmacy for filling the drug , which will not be discounted. The full amount negotiated price of brand name drugs not the discounted amount paid by the member , will count toward TrOOP. This means members will not need to spend as much to get out of the Donut Hole. For generic drugs, only the actual amount paid for the drug will be applied toward TrOOP. Drugs sold by manufacturers who do not sign an agreement will not be covered under Part D and cannot be requested by exception.

The discount is only available if Medicare Part D is the primary payer. If the prescription crosses Part D stages of coverage, i. Whether in a standard, alternative or enhanced plan, with each purchase of formulary prescription drugs during the plan year calendar year , plan members move through the four stages of Part D coverage: Beneficiaries experience different cost sharing as they move through these stages.

A "straddle" claim occurs when a prescription drug crosses multiple stages of the benefit. The plan will "prorate" the claim accordingly. Calculating what the beneficiary owes is complicated and trickier still when the plan has tiered co-pays instead of the standard benefit.

For most people, enrollment in Part D is voluntary. Most people need to select and enroll in a plan in order to have coverage. There are several Part D enrollment periods. People who become eligible for Medicare because of a disability have an IEP that begins the month they are notified of Medicare entitlement and continues for three months after. A second 7-month IEP is available for people who already have Medicare because of a disability and who turn Members are "locked in" to their chosen plan for the rest of the calendar year and cannot change plans unless they qualify for a Special Enrollment Period.

If the election is taken in February, the new coverage will begin on March 1. Note that the plan cannot terminate a member for non-payment of premiums if premiums are being withheld from Social Security. Plans must also provide a two-month grace period before terminating a member for non-payment. The notice period begins when the plan notifies the member that payment is due.

Enrollment in Part D is generally voluntary, however, some people are required to enrolled, and others should not enroll. If they do not self-enroll, Medicare will automatically enroll them in a plan.

People who have "creditable" prescription drug coverage coverage that is as good as or better than Part D are not required to enroll and are often better off in their private plans than under Part D. They should not consider enrolling in Part D without consulting with their current plan Benefits Administrator. Non-LIS eligibles who do not have creditable coverage, and who do not enroll in Part D when they are first eligible to do so, may have a Late Enrollment Penalty and may have to wait up to 12 months to enroll in a plan.

Creditable coverage is prescription drug coverage that is as actuarially as good as, or better than, Part D coverage. This notice must be in writing and it must be received before September Many Medigap policies that offer prescription drug coverage are not creditable. Individuals with Medigap policies should check with their plans. Individuals who have creditable coverage are not required to enroll in Part D and may not find it to their advantage to do so. This is because they may lose the hospital and medical coverage if they enroll in Part D.

Individuals who involuntarily lose creditable coverage are entitled to a Special Enrollment Period. They have 63 days in which to enroll in a Part D plan.

Non-payment of premium is NOT considered involuntary loss. Individuals who do not receive a notice or creditable coverage, or who receive an incorrect notice, may qualify for a SEP that allows them to enroll in Part D outside the AEP. Unless exempt, there is a penalty for not enrolling in Part D when first eligible to do so. Those exempt from the penalty include individuals who:. The base calculation changes yearly, based on the average national base premium amount.

The LEP cannot go back farther than June CMS calculates the penalty amount, which is collected by the Part D plan. There is a process to request reconsideration if a late enrollment penalty appears to be imposed in error. Medicare contracts with an independent review entity Maximus to conduct these reconsiderations and the decision is final.

The penalty must be paid during the time the penalty is being reconsidered, which can take many months. If reconsideration is granted, the beneficiary will be reimbursed for erroneous penalty charges assessed. The most commonly available are listed here. The plan change is effective the first of the month following the month of change. This effectively limits this SEP to twelve times per year. Applies to people who move into, live in, or move out of an institution such as a long term care facility NF or SNF , an intermediate care facility for the mentally retarded ICF-MR , a psychiatric, rehabilitation hospital or unit , or long term care hospital, or a "swing-bed" hospital.

It does not apply to people in acute care hospitals. This SEP includes people who: Two months from the date the person notifies the plan, or returns to the US, or is released from jail. Onset is later if the person does not notify the plan, and the plan learns of the move through CMS or the Post Office. The person involuntarily loses creditable coverage, i.

Note that failure to pay premiums does not constitute involuntary loss. Also includes changes to other coverage such that it is no longer creditable. May enroll in Part D two months from the loss of creditable coverage, or notification of the loss, whichever is later. Such as VA or TriCare. Applies to people who dropped a Medigap policy the first time they enrolled in a Medicare Advantage plan, and who wish to return to original Medicare and join a PDP.

Anytime during the month period following their enrollment in the MA plan. Also have a guaranteed right to purchase another Medigap policy, provided they are still in month trial period.

SEP may continue up to 90 days. Applies to people who elected not to enroll in Part D, or who erroneously enrolled in a Part D plan, due to an error by a Federal employee. The person is enrolled in a plan whose contract is terminated by CMS, or whose contracted is terminated by mutual consent. Plan must give members 60 days notice. Plan must give members 90 days notice. SEP to enroll in another plan begins October 1 and ends January 31 of the following year. Premiums may be paid directly to the plan, deducted from Social Security, or deduction from a bank account EFT.

Members who wish to change their method of payment during the year should contact their plan to make the change but the byword in this exchange is "patience. Individuals may not belong to more than one Part D plan at a time. In fact, enrollment in one plan automatically cancels out enrollment in the previous plan. For this reason, beneficiaries who want to switch plans need only enroll in their desired plan.

Medicare will cancel out their enrollment in their old plan. Note that individuals who wish to remain with their existing plan from one year to the next need do nothing. Their enrollment will automatically "roll over" into the next year. Evidence of Coverage EOCs. Shortly after enrolling in a plan, new members should receive a member card and a contract called the Evidence of Coverage EOC.

The formulary will show not only what drugs are covered by the plan but what restrictions may apply to some of those drugs such as prior authorization, quantity limits and step therapy. The ANOC informs members how their plan will change in the coming year, including any changes that may be made to the formulary. People should not assume that their existing plan will meet their needs or remain an appropriate choice in subsequent years.

What is Covered?