Services Provided Outside the United States - JE Part B

The term 'United States' means the 50 states, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. For purposes of services furnished on a ship, it includes the territorial waters adjoining the land areas of the United States.

Medicare provides for limited coverage for medical services furnished outside the United States. In general, hospital or medical services are not covered outside the country, with a few exceptions. The Social Security Act (SSA) specifies the following exceptions to the 'foreign' exclusion:

• Inpatient hospital services for treatment of an emergency in a foreign hospital that is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency, provided either of the following conditions exist:
  • emergency arose within the U.S.
  • emergency arose in Canada while the individual was traveling, by the most direct route and without unreasonable delay between Alaska and another State
• Inpatient hospital services at a foreign hospital that is closer to, or more accessible from, the individual's residence within the U.S. than the nearest U.S. hospital that is adequately equipped and available to treat the individual's condition, whether or not an emergency exists
• Physician and ambulance services in connection with, and during, a foreign inpatient hospital stay that is covered in accordance with either of the above
• Services rendered on board a ship in a United States port, or within six hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States territorial waters. Services not furnished in a United States port, or within six hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry.

Resources

• CMS Change Request (CR) 5427 - Services Not Provided Within United States
• CMS CR 3781 - Services Not Provided Within United States
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 10.1.4.7
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 120.2