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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Items and services furnished outside the United States are excluded from coverage except for the following
services, and certain services rendered on board a ship:
- Emergency inpatient hospital services where the emergency occurred:
o While the beneficiary was physically present in the United States; or
o In Canada while the beneficiary was traveling without reasonable delay and by the most direct
route between Alaska and another State.
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the
United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's
United States residence than the nearest participating United States hospital which was adequately
equipped to deal with and available to provide treatment of the illness or injury;
- Physician and ambulance services furnished in connection with a covered foreign hospitalization;
- Services rendered on board a ship in a United States port, or within 6 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 6 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; and
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, American Samoa and, for purposes of services rendered
on a ship, includes the territorial waters adjoining the land areas of the United States. A hospital that is not
physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is
owned or operated by the United States Government. You can find these rules in Medicare Benefit Policy
Manual Chapter 16, Section 60.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan
contract says that you are covered for emergency care worldwide. If you have an emergency outside of the
United States and its territories, you are responsible to pay for the services up front. You must submit proof of
payment, copies of medical records, contact information for the providers rendering the services, and all
supporting documentation to the Plan for reimbursement within 12 months of the date of service. The Plan may
not reimburse you for all out-of-pocket expenses and will only reimburse up to the Medicare allowable rates.
You must pay $50 copayment for emergency care services. For dates of service in 2019, you can find this
information in Chapter 4 on page 64 of the Plan's 2019 Evidence of Coverage. For dates of service in 2020,
you can find this information in Chapter 4 on page 64 of the Plan's 2020 Evidence of Coverage.