As you age, it's natural to start worrying about your health a bit more. One good way to keep track is through blood tests, which can provide insight into your body in many ways, including checking for diseases or conditions like diabetes, heart disease or thyroid problems. If caught early, many of them are manageable with treatment.
And while lab tests can be expensive thanks to the Federal Government-funded Medicare program, Americans over the age of 65 or those with certain disabilities are able to receive health insurance coverage that many would otherwise find it difficult to afford. But the question is: does Medicare cover blood tests?
What Is Original Medicare
Before we talk about blood test coverage, let us walk through some basic terminology about Medicare. The program is divided into four parts, with Part A and Part B also known as Original Medicare. And here's what they cover:
- Medicare Part A: Covers hospital stays and care. This includes expenses like a semi-private hospital room, meals, nursing, and prescription drugs. After you've paid the deductible, Part A is free for most Americans since you likely paid for it with payroll taxes during your working years.
- Medicare Part B: Covers medically necessary doctors' services, outpatient care, home health care, durable medical equipment, and many preventive services. You have to pay a monthly premium for Part B coverage, but this plan is optional. The standard Part B premium amount changes each year. It also has an annual deductible ($226 for 2023) and coinsurance, meaning you pay 20% of the amount approved by Medicare for most doctor services.
Medicare Part A Coverage of Blood Tests
When it comes to blood tests, Medicare Part A typically covers the costs if the tests are deemed medically necessary for diagnosis or treatment. Since it also covers hospital care, blood tests performed during an inpatient hospital stay or as an outpatient at a hospital facility should be fully covered.
Inpatient Hospital Care
If you are admitted to the hospital as an inpatient, Medicare Part A will cover any blood tests ordered by your doctor during your stay. These could include common tests like a complete blood count (CBC), electrolyte, kidney function tests, or more specialized tests if needed for diagnosis or monitoring of a medical condition. As long as the blood tests are directly related to the reason for your inpatient admission, there should be no out-of-pocket cost to you.
Outpatient Hospital Care
Even if you are not admitted for an overnight hospital stay, blood tests performed at a hospital outpatient clinic or emergency department should still be covered under Part A. This includes tests done to investigate symptoms or monitor an ongoing health issue. Depending on your condition or circumstances, this may include:
- Kidney function tests (BUN, creatinine)
- Liver function tests (AST, ALT, bilirubin)
- Cholesterol tests (total cholesterol, LDL, HDL, triglycerides)
- Blood sugar tests (fasting glucose, HbA1c)
While Part A provides some coverage for these medically necessary blood tests in a hospital setting, there are exceptions. Routine physical exams, diagnostic laboratory tests, tissue specimen tests, health screenings and blood work for monitoring stable conditions may not qualify.
Blood Tests Covered With Medicare Part B
Medicare Part B also covers a variety of blood tests to help diagnose and monitor health conditions, though just like Part A, they are dependent on your medical needs and risk factors. Here are some of the common ones covered by Medicare Part B:
- Complete Blood Count (CBC): Measures several components of your blood, including red blood cells, white blood cells, and platelets. It helps check for anemia or infection. Medicare covers this test once every 3 years, or more often if medically necessary.
- Basic Metabolic Panel: Measures blood sugar, electrolyte and fluid balance, kidney function, and liver function. It provides an overview of your body’s chemical balance and is often used as a first-line test for general health screening. Medicare covers this test once every year.
- Lipid Panel Test: A lipid panel measures cholesterol levels, including HDL (good cholesterol), LDL (bad cholesterol), and triglycerides. High cholesterol is a risk factor for heart disease, so Medicare covers this test once every 5 years, or more frequently if you have heart disease or high cholesterol.
- Thyroid: Medicare covers blood tests to check thyroid hormone levels, including TSH, T3, and T4. These tests help diagnose thyroid disorders like hypothyroidism or hyperthyroidism. The frequency of coverage depends on your medical needs and risk factors.
Blood Tests for Diagnosing a Medical Condition
When diagnosing a medical condition, your doctor may order blood tests to help determine the cause of your symptoms or abnormal findings. Medicare Part B covers most medically necessary blood tests.
- Blood Chemistry Tests: These tests analyze the levels of substances like glucose, electrolytes, proteins, and enzymes in your blood. They are often used to check for diabetes, liver or kidney disease, and other disorders. Basic blood chemistry tests, like a metabolic panel, are typically covered under Medicare Part B with no out-of-pocket costs.
- Tumor Marker Tests: Certain blood tests can detect high levels of proteins that may indicate the presence of cancer. Prostate-specific antigen (PSA) tests, for example, are used to screen for prostate cancer in men. While Medicare Part B covers PSA tests once every 12 months, they will only cover additional tests if you have symptoms or a diagnosis of cancer.
- Thyroid Function Tests: Checks levels of thyroid hormones TSH, T3 and T4. Used to diagnose hyperthyroidism or hypothyroidism.
- Hepatitis: Screens for hepatitis A, B and C infections which can lead to liver disease.
- HIV: Detects antibodies and antigens to determine if you have the human immunodeficiency virus (HIV).
Does Medicare Cover Routine Blood Testing?
In addition, Medicare Part B covers some routine blood testing to check for health issues or monitor a known medical condition, though again, the coverage and out-of-pocket costs for these tests will depend on whether they are medically necessary.
The following are examples of routine or preventive blood testing that’s not medically necessary hence may not be covered by Medicare.
- Comprehensive metabolic panels and cardiac risk panels.
- Vitamin, mineral and nutrient level testing without a known deficiency.
- Heavy metal toxicity testing without symptoms or exposure risks.
- Baseline tests for “wellness” or health optimization purposes.
If Medicare denies coverage for a blood test, you'll have to pay the full cost out of pocket. The exact prices will depend on the specific tests ordered by your doctor. Make sure to check with your provider about potential costs before agreeing to any testing not medically necessary.
Do Medicare Advantage Plans Cover Blood Tests?
Now that we've discussed coverage for Original Medicare, let's look at Medicare Advantage Plans (Medicare Part C). Most Medicare Advantage plans cover diagnostic blood tests as they are crucial for detecting health issues, managing chronic conditions, and monitoring treatment plans.
Many Medicare Advantage plans require prior authorization from your doctor for certain blood tests. While diagnostic tests are typically covered, some plans may charge for elective or preventive screening tests. If cost is a concern, be sure to compare Medicare Advantage plans in your area to find one with affordable blood test coverage. Every Medicare Advantage plan is different, meaning there is something for everyone.
How do I Join a Medicare Advantage Plan?
When you first become eligible for Medicare, you can join a Medicare Advantage plan during your Initial Enrollment Period. This is a window (exactly 7 months) that includes the 3 months before you turn 65, the month you turn 65, and the 3 months after you turn 65. If you enroll during this time, your coverage will start the first of the month after you sign up.
If you don't join during your Initial Enrollment Period, you'll have to wait for the Annual Enrollment Period which runs from October 15th to December 7th each year. During this time, you can switch from Original Medicare to a Medicare Advantage plan, switch between Medicare Advantage plans, or drop your Medicare Advantage plan and go back to Original Medicare. Changes made during this time will take effect on January 1st of the following year.
What to Consider With Medicare Advantage Plans
When choosing Medicare Advantage Plans in your area, compare factors like cost, coverage, networks, prescription drug coverage and additional benefits. You can compare plans on Medicare.gov or work with a medical insurance broker. When you find a plan you want to join, you can enroll on the plan's website, over the phone, or sometimes even in person.
Need Blood Test Coverage With Your Medicare Plan?
Like we mentioned before, every Medicare Advantage plan is different, so they can be difficult to navigate. If blood testing coverage is important to you but your current plan doesn't cover it, we'll not only find you a plan that does, but one that meets all of your needs and wants! We're here to help you find a plan that's perfect for you.
EASY Insurance is a team of experienced agents that are dedicated to helping you find the Medicare plan that best suits your needs. Whether you need an Original Medicare plan or a Medicare Advantage plan, we're happy to take the time to help you out.
We're here for you and can't wait to help you live an EASY life!