Medicare covers most diagnostic tests deemed medically necessary by a qualified healthcare provider - including blood tests.
Yes, Medicare does cover blood tests under some circumstances. However, this depends on a wide variety of factors, including your risk status and what the test is for. Although tests can be covered, there are plenty of situations under which they won’t be.
We’ll go through when blood tests are covered, how they function in each part of Medicare as well as Medicare Advantage, and the role that Medigap plans can play in getting blood work covered.
Understanding Medical Necessity
To determine whether a procedure is covered, Medicare will apply a guideline known as medical necessity. As the name implies, medical necessity is just a designation by your healthcare provider that a procedure is necessary for your health.
In most cases, medical necessity is the main thing that determines coverage. For example, although dental care isn’t usually covered by Medicare, it may be covered if your doctor notes that it is medically necessary, as can happen after a serious injury.
This also goes for blood work. The details vary slightly, but as a general rule, you can expect medically necessary blood work to be covered by Medicare medical insurance. If your doctor needs to test your blood to determine something related to your health, you can expect coverage. On the other hand, if you want a test performed but it hasn’t been ordered by your doctor, you may have to pay for the blood work yourself.
What Types of Tests Can Be Covered?
Many different types of laboratory tests can be covered by Medicare in different situations. This includes screening tests, urinalysis, hepatitis testing, pap smears, prostate-specific antigen (PSA) tests, and more. Some of these tests will be covered on a specific schedule, and others may be ordered by your doctor.
Coverage for High-Risk Patients
If your doctor determines that you are at a higher risk for heart disease or heart attacks, you will be able to receive diagnostic blood tests more easily. This more frequent lab work will help your doctor create a more appropriate program for preventative care given your condition.
Coverage Under Medicare Part A
Medicare Part A health insurance is often referred to as your hospital insurance. More accurately, Part A covers inpatient care. This can refer to hospitals, skilled nursing facilities, or hospice care. If you have been admitted as an inpatient, your coverage will come from Medicare Part A.
Blood test coverage under Part A is simple. If blood work is ordered by a healthcare provider who is treating you as an inpatient, Part A will cover it. The only thing to keep in mind is that you must meet your deductible before Part A can provide you with coverage.
Blood Test Medicare Coverage with Part B
Medicare Part B provides coverage for all medically necessary outpatient healthcare, aside from prescription drug coverage. Part B covers most of the healthcare that you ordinarily receive, including doctor visits and diagnostic tests. Part B will cover your annual wellness check, and a blood test may be included in that coverage.
If your doctor orders a blood test outside of a hospital, it will likely be covered by Part B. The general requirements for coverage by Part B, when compared to Part A, are the same -- medical necessity. The main difference is where these tests are performed, which determines which part of Medicare will apply to that procedure.
Medicare Part B will cover several common lab tests that are used for preventative and diagnostic care. This includes cholesterol, lipid, and triglyceride tests every five years.
Coverage with Medicare Part C (Medicare Advantage)
Medicare Advantage, also known as Part C, is a way of receiving your Medicare benefits through a private insurance company. This can be a good option for some, as there are additional incentives and benefits involved. However, it’s not a good fit for everyone’s situation and includes some unique qualities.
When it comes to blood work, Medicare Advantage insurance will function in a fairly simple way. Medicare Advantage is required to cover at least the same things that Original Medicare covers, which means that the same guidelines given above will apply to your Medicare Advantage plan.
However, Medicare Advantage plans can use provider networks to restrict the providers that they fully cover. If you have one of these plans, make sure that you visit an in-network provider for all of your healthcare needs.
Additionally, Medicare Part C plans are allowed to cover more than Original Medicare covers. This means that they may cover blood work in some situations where Original Medicare does not cover it. While this isn’t particularly common, it is a possibility.
Do Medicare Part D Plans Offer Any Blood Work Coverage?
No, Medicare Part D plans do not offer any coverage for blood tests. These private insurance plans offer prescription drug coverage exclusively, so you won’t get any blood work coverage with Part D plans. While these plans are very useful for many, they don’t contribute to blood work in particular.
Medigap Plans and Blood Testing
Medigap plans, also known as Medicare Supplement insurance plans, are plans offered by private insurance companies that can help provide coverage for your out-of-pocket costs under Original Medicare. These plans will pay for things like your coinsurance and copayments under Part A and Part B of Medicare.
Although these plans are geared towards covering out-of-pocket costs rather than actual healthcare, some plans will cover the first 3 pints of blood that you have drawn during a given benefit period.
Whether or not these plans are viable financially depends on your particular situation and needs. Each plan will be priced differently depending on your location and which company you buy from, so make sure to investigate in detail before committing.
You can find a comprehensive comparison of Medigap plans from www.medicare.gov.
Blood Test Coverage Under Medicaid
Finally, let's take a look at your blood test coverage under Medicaid. Medicaid coverage won’t always overlap with Medicare, but some individuals qualify for both.
Medicaid coverage varies from state to state, so you should make sure to check the coverage details in your state if you qualify. However, blood tests will be covered by Medicaid in the vast majority of cases.
How Much Do Blood Tests Cost?
If you want to get a blood test done and are going to pay on your own, the costs can vary widely. Simple tests can cost as little as $10, while multiple complex tests can cost several thousands of dollars. Make sure to keep an eye on the price before you make any purchases.
Things to Keep in Mind Regarding Medicare and Blood Tests
As you can see, getting a medically necessary blood test covered by Medicare is a fairly simple process. Whether you have Original Medicare or Medicare Advantage, your blood tests will usually be covered if ordered by your doctor. Additional coverage from Medigap plans can help, but tests that you choose to get without your doctor’s orders won’t be covered.
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