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Services Covered by Medicare Part A and Part B

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Services Covered by Medicare Part A and Part B

Tuesday, July 11, 2017 2:47 PM

Medicare covers many tests, items and services like lab tests, surgeries, and doctor visits – as well as supplies, like wheelchairs and walkers. In general, Part A covers things like hospital care, skilled nursing facility care, hospice, and home health services. Medicare Part B covers medically necessary services and preventative services.

The partial-list of Medicare covered services below will help you learn about some of the services covered by Medicare and basic information about each. You can find out if your test, item, or service is covered by visiting Medicare.gov here. Talk to your doctor or other health care provider about why you need certain services or supplies and find out if Medicare will cover them. Whether you have Original Medicare or a Medicare Advantage Plan, your plan must give you at least the same coverage as Original Medicare, but always check with your plan as you may have different rules.

Medicare-covered services include, but are not limited to:

Eyeglasses (Limited)

Medicare covers one pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Note: Medicare will only pay for contact lenses or eyeglasses provided by a supplier enrolled in Medicare, no matter who submits the claim (you or your provider).

Diabetes Supplies

Medicare covers blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Medicare only covers insulin if it’s medically necessary and you use an external insulin pump to administer the insulin. You pay 20% of the Medicare-approved amount, and the part b deductible applies.

Note: Medicare prescription drug coverage (Part D) may cover insulin, certain medical supplies used to inject insulin (like syringes), and some oral diabetic drugs. Check with your plan for more information.

You may need to use specific suppliers for some types of diabetic testing supplies. Visit medicare.gov/supplierdirectory to find a list of suppliers for your area.

Diabetes screenings

Medicare covers these screenings if your doctor determines you’re at risk for diabetes. You may be eligible for up to 2 diabetes screenings each year. You pay nothing for the test if your doctor or other qualified health care provider accepts assignment.

Diabetes Self-Management Training

Medicare covers diabetes outpatient self-management training to teach you to cope with and manage your diabetes. The program may include tips for eating healthy, being active, monitoring blood sugar, taking medication, and reducing risks. You must have diabetes and a written order from your doctor or other health care provider. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Blood

If the provider gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. However, you’ll pay a copayment for the blood processing and handling services for each unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

Ambulatory Surgical Centers

Medicare covers the facility service fees related to approved surgical procedures provided in an ambulatory surgical center (facility where surgical procedures are performed, and the patient is expected to be released within 24 hours).

Except for certain preventive services (for which you pay nothing if the doctor or other health care provider accepts assignment), you pay 20% of the Medicare-approved amount to both the ambulatory surgical center and the doctor who treats you, and the Part B deductible applies. You pay all of the facility service fees for procedures Medicare doesn’t cover in ambulatory surgical centers.

Durable Medical Equipment (DME)

Medicare covers items like oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented. You pay 20% of the Medicare -approved amount, and the Part B deductible applies.

Abdominal Aortic Aneurysm Screening

Medicare covers a one-time screening abdominal aortic aneurysm ultrasound for people at risk. You must get a referral from your doctor or other practitioner. You pay nothing for the screening if the doctor or other qualified health care provider accepts assignment.

Note: If you have a family history of abdominal aortic aneurysms, or you’re a man 65–75 and you’ve smoked at least 100 cigarettes in your lifetime, you’re considered at risk.

Depression screening

Medicare covers one depression screening per year. The screening must be done in a primary care setting (like a doctor’s office) that can provide follow-up treatment and referrals.

You pay nothing for this screening if the doctor or other qualified health care provider accepts assignment.

Advance Care Planning

Medicare covers voluntary advance care planning as part of the yearly “wellness” visit. This is planning for care you would want to get if you become unable to speak for yourself.

You can talk about an advance directive with your health care professional, and he or she can help you fill out the forms, if you want to. An advance directive is a legal document that records your wishes about medical treatment at a future time if you’re not able to make decisions about your care. You pay nothing if the doctor or other qualified health care provider accepts assignment.

Note: Medicare may also cover this service as part of your medical treatment. When advance care planning isn’t part of your annual “wellness” visit, the Part B deductible and coinsurance apply.

Cardiovascular Disease (Behavioral Therapy)

Medicare will cover one visit per year with a primary care doctor in a primary care setting (like a doctor’s office) to help lower your risk for cardiovascular disease. During this visit, the doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you eat well. You pay nothing if the doctor or other qualified health care provider accepts assignment.

Cardiovascular Disease Screenings

These screenings include blood tests that help detect conditions that may lead to a heart attack or stroke.

Medicare covers these screening tests once every 5 years to test your cholesterol, lipid, lipoprotein, and triglyceride levels. You pay nothing for the tests if the doctor or other qualified health care provider accepts assignment.

Alcohol Misuse Screening and Counseling

Medicare covers one alcohol misuse screening per year for adults with Medicare (including pregnant women) who use alcohol, but don’t meet the medical criteria for alcohol dependency.

If your primary care doctor determines you’re misusing alcohol, you can get up to four brief face-to-face counseling sessions per year (if you’re competent and alert during counseling). A qualified primary care doctor or other practitioner must provide the counseling in a primary care setting (like a doctor’s office). You pay nothing if the qualified primary care doctor or other primary care practitioner accepts assignment.

Doctor and Other Health Care Provider Services

Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you’re a hospital inpatient) and covered preventive services. Medicare also covers services provided by other health care providers, like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists. Except for certain preventive services (for which you may pay nothing), you pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Emergency Department Services

These services are covered when you have an injury, a sudden illness, or an illness that quickly gets much worse.

You pay a specified copayment for the hospital emergency department visit, and you pay 20% of the Medicare-approved amount for the doctor’s or other health care provider’s services. The Part B deductible applies. However, your costs may be different if you’re admitted to the hospital as an inpatient.

Ambulance Services

Medicare covers ground ambulance transportation when you need to be transported to a hospital, critical access hospital, or skilled nursing facility for medically necessary services, and transportation in any other vehicle could endanger your health. Medicare may pay for emergency ambulance transportation in an airplane or helicopter to a hospital if you need immediate and rapid ambulance transportation that ground transportation can’t provide.

In some cases, Medicare may pay for limited, medically necessary, non-emergency ambulance transportation if you have a written order from your doctor stating that ambulance transportation is medically necessary. An example may be a medically necessary ambulance transport to a renal dialysis facility for an end-stage renal disease (ESRD) patient.

Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need. You pay 20% of the Medicare - approved amount, and the Part B deductible applies.

Bone Mass Measurement (Bone Density)

This test helps to see if you’re at risk for broken bones. It’s covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria.

You pay nothing for this test if the doctor or other qualified health care provider accepts assignment.

Cardiac Rehabilitation

Medicare covers comprehensive programs that include exercise, education, and counseling for patients who meet at least one of these conditions:

  • A heart attack in the last 12 months
  • Coronary artery bypass surgery
  • Current stable angina pectoris (chest pain)
  • A heart valve repair or replacement
  • A coronary angioplasty (a medical procedure used to open a blocked artery) or coronary stenting (a procedure used to keep an artery open)
  • A heart or heart-lung transplant Medicare also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than regular cardiac rehabilitation programs. Services are covered in a doctor’s office or hospital outpatient setting. You pay 20% of the Medicare-approved amount if you get the services in a doctor’s office. In a hospital outpatient setting, you also pay the hospital a copayment. The Part B deductible applies.

Breast Cancer Screening (Mammograms)

Medicare covers screening mammograms to check for breast cancer once every 12 months for all women with Medicare who are 40 and older. Medicare covers one baseline mammogram for women between 35–39. You pay nothing for the test if the doctor or other qualified health care provider accepts assignment.

Note: Part B also covers diagnostic mammograms more frequently than once a year when medically necessary. You pay 20% of the Medicare-approved amount for diagnostic mammograms, and the Part B deductible applies.

Cervical and Vaginal Cancer Screenings

Part B covers pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, Medicare also covers a clinical breast exam to check for breast cancer. Medicare covers these screening tests once every 24 months. Medicare covers these screening tests once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal pap test in the past 36 months.

Part B also covers human papillomavirus (HPV) tests (when received with a pap test) once every 5 years if you’re age 30– 65 without HPV symptoms. You pay nothing for the lab pap test or for the lab HPV with pap test if your doctor or other qualified health care provider accepts assignment. You also pay nothing for the pap test specimen collection and pelvic and breast exams if the doctor or other qualified health care provider accepts assignment.

Chemotherapy

Medicare covers chemotherapy in a doctor’s office, freestanding clinic, or hospital outpatient setting for people with cancer. You pay a copayment for chemotherapy in a hospital outpatient setting. For chemotherapy given in a doctor’s office or freestanding clinic, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. For chemotherapy in a hospital inpatient setting covered under Part A, see hospital care (inpatient care).

Chiropractic Services (Limited Coverage)

Medicare covers manipulation of the spine if medically necessary to correct a subluxation (when one or more of the bones of your spine move out of position) when provided by a chiropractor or other qualified provider. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Note: You pay all costs for any other services or tests ordered by a chiropractor (including x-rays and massage therapy).

Chronic Care Management Services

If you have 2 or more chronic conditions that are expected to last at least a year, Medicare may pay for a health care provider’s help to manage those conditions. This includes a comprehensive care plan that lists your health problems and goals, other health care providers, medications, community services you have and need, and other information about your health. It also explains the care you need and how your care will be coordinated. A chronic condition could be arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, and other conditions. Your health care provider will ask you to sign an agreement to provide this service. If you agree, he or she will prepare the care plan, help you with medication management, provide 24/7 access for urgent care needs, give you support when you go from one health care setting to another, review your medicines and how you take them, and help you with other chronic care needs. There’s a monthly fee, and the Part B deductible and coinsurance apply.

Clinical Research Studies

Clinical research studies test how well different types of medical care work and if they’re safe. Medicare covers some costs, like office visits and tests, in qualifying clinical research studies.

You may pay 20% of the Medicare-approved amount, and the Part B deductible may apply.

Note: If you’re in a Medicare Advantage plan (like an HMO or PPO) will cover some of the costs through Part A and Part B benefits, but contact your plan for more detailed information.

Colorectal Cancer Screenings

Medicare covers these screenings to help find precancerous growths or cancer early, when treatment is most effective. One or more of these tests may be covered:

  • Multi-target stool DNA test —this lab test is generally covered once every 3 years if you meet all of these conditions:
    • Are between ages 50–85.
    • Show no symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test.
    • At average risk for developing colorectal cancer, meaning:
      • Have no personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
      • Have no family history of colorectal cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

You pay nothing for the test if the doctor or other qualified health care provider accepts assignment.

  • Screening fecal occult blood test —This test is covered once every 12 months if you’re 50 or older. You pay nothing for the test if the doctor or other qualified health care provider accepts assignment.
  • Screening flexible sigmoidoscopy —This test is generally covered once every 48 months if you’re 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. You pay nothing for the test if the doctor or other qualified health care provider accepts assignment.
  • Screening colonoscopy —This test is generally covered once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. There’s no minimum age. You pay nothing for the test if the doctor or other qualified health care provider accepts assignment.

    Note: If a polyp or other tissue is found and removed during the colonoscopy, you may have to pay 20% of the Medicare-approved amount for the doctor’s services and a copayment in a hospital outpatient setting. The Part B deductible doesn’t apply.

  • Screening barium enema —This test is generally covered once every 48 months if you’re 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-approved amount for the doctor services. In a hospital outpatient setting, you also pay the hospital a copayment. The Part B deductible doesn’t apply.

Continuous Positive Airway Pressure (CPAP) Therapy

Medicare covers a 3-month trial of CPAP therapy if you’ve been diagnosed with obstructive sleep apnea. Medicare may cover it longer if you meet in person with your doctor, and your doctor documents in your medical record that the CPAP therapy is helping you.

You pay 20% of the Medicare-approved amount for rental of the machine and purchase of related supplies (like masks and tubing), and the Part B deductible applies. Medicare pays the supplier to rent the machine for 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it.

Note: If you had a CPAP machine before you got Medicare, Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements.

If you live in certain areas of the country, you may have to use specific suppliers for Medicare to pay for a CPAP machine and/or accessories.

Defibrillator (Implantable Automatic)

Medicare covers these devices for some people diagnosed with heart failure. If the surgery takes place in an outpatient setting, you pay 20% of the Medicare-approved amount for the doctor’s services.

If you get the device as a hospital outpatient, you also pay the hospital a copayment. In most cases, the copayment amount can’t be more than the Part A hospital stay deductible. The Part B deductible applies. Part A covers surgeries to implant defibrillators in a hospital inpatient setting. See hospital care (inpatient care)

EKG or ECG (Electrocardiogram) Screening

Medicare covers a one-time screening EKG/ECG if referred by your doctor or other health care provider as part of your one-time “Welcome to Medicare” preventive visit. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. An EKG/ECG is also covered as a diagnostic test. If you have the test at a hospital or a hospital-owned clinic, you also pay the hospital a copayment.

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Last Revised 11/15/2017