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Medicare Coverage Abroad When Treatment Isn’t Available in the United States

Q. I need a treatment that I can get in another country (Switzerland or Argentina) but isn’t yet available in the United States. Will Medicare cover my costs abroad in these circumstances?

A. Medicare doesn’t usually cover treatment abroad, as explained here.

One of the few exceptions allowed, according to Medicare regulations, is for “inpatient hospital services at a foreign hospital that is closer to, or more accessible from, the individual’s residence within the United States than the nearest U.S. hospital that is adequately equipped and available to treat the individual’s condition, whether or not an emergency exists.” In other words, the rule allows beneficiaries living close to U.S. borders to be treated at hospitals in Canada or Mexico that are nearer than an American hospital.

However, the rule doesn’t specifically address a situation where the treatment in question is not offered in any U.S. hospital. Asked to clarify this point, Medicare officials say: “If the service is so experimental that no hospital in the U.S. furnishes it, then it is very unlikely that Medicare would pay for the service.”

They say that in this situation, you “could always attempt to appeal Medicare’s denial [of payment].” First you’d have to undergo treatment, pay for it out of pocket and then put in a claim to Medicare. But, the officials say, “We believe that Medicare would ultimately deny a claim for services furnished in [foreign countries such as Switzerland or Argentina].”

If your claim is denied, you have the right to go through several levels of appeal. Since this kind of case would involve challenging Medicare regulations, you’d probably need a lawyer experienced in Medicare law to argue it for you. To find such help, consult the Eldercare Locator or your state health insurance assistance program, both of which can direct you to appropriate legal services.

Patricia Barry is a senior editor at the AARP Bulletin.

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