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Medicare and Blood Tests

blood test in a labMedicare Original (Part A and Part B) generally covers laboratory tests, including blood tests that a doctor has determined to be medically necessary. These blood tests are used to screen for medical conditions such as Diabetes to cardiovascular disease.

Blood tests are covered under Medicare. These tests are covered when ordered by a health professional or doctor and used for diagnosing or monitoring a disease or medical condition.

To qualify for coverage, the doctor must prove that the blood test is medically necessary. Exemptions are when blood tests are performed as part of screening or a general physical exam.

However, Medicare Part B can cover screenings for Diabetes provided it meets certain requirements.

Medicare Part A (hospital insurance) provides coverage for blood tests performed at a hospital or skilled nursing facility. If blood tests are ordered in an outpatient setting such as a doctor’s office or health clinic, coverage falls under Medicare Part B (medical insurance).

What are the Common Blood Tests Covered by Medicare?

Original Medicare (Part A or Part B) covers blood tests for in-patient and out-patient care. These are covered when a doctor deems it necessary to monitor or diagnose a medical condition. Common blood test covered by Medicare include:

1. Sexually Transmitted Infections (STI) Tests – blood tests used to detect Syphilis, Gonorrhea, Hepatitis B, and Chlamydia. Tests are usually covered every 12 months or in certain cases during pregnancy.

2. Diabetes – Medicare B provides covers two blood tests for diabetes screenings for people who qualify for 2 or more conditions. Blood tests are covered for people who are 65 year or older, overweight, and those with a family history of diabetes or gestational diabetes.

People can also qualify for two Medicare covered blood tests for diabetes screening when a doctor identifies risk factors such as obesity, history of high blood sugar, high blood pressure, and history of abnormal cholesterol levels.

3. Hepatitis C – coverage is available for a one-time test and additional annual screening for those identified as at high risk for Hepatitis C. However, blood test must be ordered by a primary care doctor or health professional to qualify for coverage.

4. Prostate Cancer – Prostrate Specific Antigen (PSA) screening is performed by analyzing the levels of PSA in a man’s blood gathered from a blood test. In general, PSA tests are covered every 12 months upon recommendation of a health professional.

5. Cardiovascular Disease – Medicare covers blood tests conducted every five years to detect cardiovascular disease. This is subject to doctor orders.

How Much Will Medicare Pay?

For people with Medicare (Plan A or Part B) and would like to get coverage for their blood test, it is important that they first consult their doctor to check the purpose of the blood test. Medicare has clear guidelines on what it accepts as covered blood tests.

Upon determining that the blood test is covered under Medicare, the next step is to determine if the procedure will be conducted in an in-patient or out-patient setting.

In-patient blood tests are covered under Medicare Part A. The cost is subject to Medicare (Part A) deductible per benefit period. The benefit period is especially important for Medicare (Part A) because deductibles are based on the benefit period and not the calendar year.

All blood tests performed in an outpatient setting are fully covered under Medicare (Part B), if it is done in a Medicare-approved facility. For non-approved facilities, a coinsurance payment may be required. Medicare benefits kick in after the patient pays the deductible. Medicare covers 80 percent of blood testing costs.

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