Joel Mekler | Medicare Moments: Does Medicare cover blood tests? | Lifestyles

Most of the blood tests needed to diagnose a problem, catch a health problem early, and stay healthy are covered by Medicare. But sometimes, Medicare blood test coverage isn’t always so straight-forward and dry.

•What common blood tests are covered by Medicare? Some of the blood tests covered by Medicare include tests for:

1. Diabetes: Medicare covers a blood test for diabetes once a year, or up to twice a year for high-risk people who have risk factors such as a history of high blood pressure or hypertension, a history of high blood pressure abnormal cholesterol or triglyceride levels, a history of blood sugar or obesity.

2. Heart disease: A blood test is covered by Medicare once every five years to check your cholesterol, lipids (fats in the blood), and triglycerides to determine if you are at risk for a heart attack or stroke.

3. HIV: Medicare covers annual blood tests for HIV testing based on risk. Pregnant women can have a Medicare-covered HIV blood test up to 3 times during their pregnancy.

4. Hepatitis B & C: Medicare covers testing for HBV infection if you are at high risk for hepatitis B or are pregnant. The blood test is covered once a year if you are high risk and is covered at different times during your pregnancy, depending on your level of risk. Medicare covers hepatitis C blood tests each year if you are at increased risk or meet certain other factors.

5. Colorectal cancer: Medicare covers a fecal occult blood test once a year if you are 50 or older and have a referral from your doctor or other healthcare professional

6. Prostate cancer: Once a year. Medicare covers prostate-specific antigen (PSA) blood tests for men over 50.

7. Various sexually transmitted diseases: Medicare annually covers blood tests for sexually transmitted infections (STIs). The tests can detect chlamydia, syphilis, hepatitis B and gonorrhea.

8. Coronavirus disease 10 (COVID-19) antibody test: Also called serological testing, coronavirus testing is covered to see if your immune system has responded to exposure and infection from COVID-19.

• What part of Medicare covers blood tests? The original Medicare (Parts A and B) will only cover blood tests at Medicare-approved testing facilities. These facilities accept Medicare payment. This includes where the blood was drawn and the lab performing the test (if not on site).

Blood tests performed while in hospital or in a skilled nursing facility are usually covered by Medicare Part A (hospital insurance). Blood tests ordered as part of outpatient treatment received at a doctor’s office or health clinic will be covered by Medicare Part B (medical insurance).

• How much does Medicare pay for blood tests? If a person with Original Medicare goes to a Medicare-approved lab, they usually pay nothing for most diagnostic tests. However, there are exceptions where a person may have to pay some or all of the cost, such as when a doctor orders a lab test more often than Medicare coverage allows or when a doctor orders a lab test that Medicare does not cover.

To help cover costs when Medicare does not cover blood tests, people with Original Medicare can purchase a Medigap plan, which is Medicare supplemental insurance, from a private company.

• Does Medicare Advantage pay for blood tests? At a minimum, Medicare Advantage plans must offer the same services as Medicare Parts A and B. Many Advantage plans include benefits beyond what the original Medicare covers. A person with Medicare Advantage may be responsible for copayments and coinsurance. These costs vary by plan. A person with a Medicare Advantage plan may also need to visit an in-network lab for lower costs and may need to get a referral from their primary physician.

• Does health insurance provide coverage for routine blood tests? In most cases, no. Medicare likely won’t cover routine blood tests ordered without medical justification. Many people would have routine blood tests during their annual pre-Medicare physical. Well, it won’t be the same once you’re on Medicare.

Medicare covers a Medicare welcome visit within the first 12 months of your Part B effective date and an annual wellness visit every year thereafter. These two preventative visits are not as comprehensive as your typical annual physical exam, so routine blood work is not part of these visits. If your provider has a reason to order the blood test, Medicare may cover that test. Otherwise, you would pay 100% of the cost of blood tests that Medicare does not cover.

•Why doesn’t Medicare pay for my blood test? As just described, blood tests are covered by Medicare if your doctor deems it medically necessary. When a doctor orders a blood test, he provides the laboratory with a justification for ordering it. This is called diagnosis. Many blood tests have limited coverage; a test will only be covered for specific diagnoses. If the diagnosis is not one that Medicare accepts as the reason for testing, they probably won’t pay for it.

Coding and medical necessity are two critical factors for blood work and Medicare coverage. Remember that you will receive an invoice if you need to pay anything for the service, and your Explanation of Benefits (EOB) should give you more details about the service. If Medicare denies a service, the reason for the denial will be on the EOB.

(Joel Mekler is a Certified Senior Counselor. Send your Medicare questions to him at [email protected]{/em})

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