There are items and services for which Medicare will not pay.
Notice of Exclusions from Medicare Benets (NEMB)
• Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits.
Some items and services are not Medicare benets and Medicare will not pay for them.
• When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it, personally or through
any other insurance that you may have.
• The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or
services, knowing that you will have to pay for them yourself.
Before you make a decision, you should read this entire notice carefully.
• Ask us to explain, if you don’t understand why Medicare won’t pay.
• Ask us how much these items or services will cost you (Estimated Cost: N/A ).
Patient Signature
* This is only a general summary of exclusions from Medicare benefits. It is not a legal document. The official Medicare program
provisions are contained in relevant laws, regulations, and rulings.
I HAVE READ & UNDERSTAND THAT MEDICARE IMPOSED A THERAPY CAP IN 2021 & BENEFITS FOR PHYSICAL & SPEECH
THERAPY COMBINED MAY NOT EXCEED $2,110.00 .
Patient Signature _________________________________________________Date ___________________________________
Patient Printed Name ______________________________________________
Medicare will not pay for:
Physical Therapy and Speech Language Pathology services over $2,110.00 in
2021. **You may receive covered services through a hospital outpatient therapy department.
1. Because it does not meet the denition of any Medicare benet
2. Because of the following exclusion * from Medicare benets:
Personal comfort items
Most shots (vaccinations)
Hearing aids and hearing examinations
Most outpatient prescription drugs
Orthopedic shoes and foot supports (orthotics)
Health care received outside of the USA
Services required as a result of war
Services paid for by a governmental entity that is not Medicare
Services for which the patient has no legal obligation to pay
Home health services furnished under a plan of care, if the agency does not submit the claim
Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997
Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of
Health and Human Services (except in a case of urgent need)
Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient,
unless they are furnished under arrangements by the hospital
Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF) or of a part of a facility that
includes a SNF, unless they are furnished under arrangements by the SNF
Services of an assistant at surgery without prior approval from the peer review organization
Outpatient occupational and physical therapy services furnished incident to a physician’s services
Routine physicals and most tests for screening
Routine eye care, eyeglasses and examinations
Cosmetic surgery
Dental care and dentures (in most cases)
Routine foot care and flat foot care
Services by immediate relatives
Services under a physician’s private contract
Medicare Supplemental Forms | Exclusion(s) from Covered Benets
Please fill out this form completely. Thank You!
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