As you get older, an effective way of keeping track of your health is through blood tests. Not only can they give you multiple insights into the state of your body, but they also can help you catch many hidden diseases and conditions early — diabetes, cardiovascular disease, or thyroid problems — so you can manage them with treatment.
Yet these lab tests can be expensive. Many people, especially retirees with no or little income, may find having to take them regularly to be unaffordable in the long run. Thanks to the Federal Government-funded Medicare program, Americans over the age of 65 or those with certain disabilities now have access to affordable Medicare health insurance coverage.
The Original Medicare
Before we get into Medicare’s blood test coverage, let’s us first walk through some basic terminology about the program. Medicare is divided into four parts. Part A and Part B together are known as Original Medicare.
Medicare Part A covers expenses incurred by inpatient hospital stays and care, such as semi-private hospital rooms, meals, nursing, and prescription drugs given during a hospital stay. Part A is free for most Medicare beneficiaries after they paid the deductible.
Medicare Part B covers doctors’ services, outpatient care, home health care, durable medical equipment, and many preventive services that are deemed medically necessary. While Part B is optional, it requires you to pay a monthly premium if enrolled. This premium amount changes every year, and comes with an annual deductible ($240 for 2024) and coinsurance, meaning you pay 20% of the Medicare approved amount for most doctor services.
What Blood Tests are Covered by Part A?
Part A typically covers the costs of blood tests that are deemed medically necessary for diagnosis or treatment. Since Part A also covers inpatient stays, blood tests conducted during hospital care or as an outpatient at a hospital facility should be fully covered.
Hospital Care
When you are admitted as an inpatient, all your blood tests ordered by your doctors during the hospital stay should be fully covered by Part A. These tests may include basic tests such as complete blood count (CBC), electrolyte, kidney function tests, or more specialized diagnostic tests or those for the monitoring of a medical condition. As long as these test are ordered by your doctors and are related to why you are admitted, you shouldn’t have to pay any out-of-pocket expense.
Outpatient Hospital Care
Even if you are not staying at the hospital overnight, Part A should still cover blood tests performed at a hospital outpatient clinic or emergency department. These tests can be for the purposes of investigating symptoms or monitoring an ongoing health issue, which may include the following:
Kidney function tests (BUN, creatinine)
Liver function tests (AST, ALT, bilirubin)
Cholesterol tests (total cholesterol, LDL, HDL, triglycerides)
Blood sugar tests (fasting glucose, HbA1c)
You should note that even as Part A covers some of these medically necessary blood tests in a hospital setting, there are exceptions. It may not cover any routine physical exams, diagnostic laboratory tests, tissue specimen tests, health screenings, and blood work for monitoring stable conditions.
What Blood Tests are Covered by Part B?
While Part A primarily deals with blood tests done in an inpatient hospital setting, Part B
covers different blood tests that can help diagnose and monitor health conditions. But like Part A, the amount of coverage by Part B will also need to take into account your medical needs and risk factors. The following are some tests that are typically covered by Part B.
Complete Blood Count (CBC): Measures several of your blood components such as red blood cells, white blood cells, and platelets. The test’s aim is to check for anemia or infection. Medicare pays for 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. The purpose of the test is to give a full picture 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 are useful in detecting and diagnosing thyroid disorders like hypothyroidism or hyperthyroidism. The frequency of coverage depends on your medical needs and risk factors.
Does Medicare Cover Blood Tests for Diagnosing a Condition?
Your doctor may order blood tests when diagnosing a medical condition. These tests are covered by Part B if they are deemed medically necessary. Here are some examples:
Blood Chemistry Tests: Analyze the levels of substances like glucose, electrolytes, proteins, and enzymes in your blood. These tests are often used to check for diabetes, liver or kidney disease, and other disorders. Medicare Part B typically covers basic blood chemistry tests, like a metabolic panel, with no out-of-pocket costs.
Tumor Marker Tests: Some blood tests can detect high levels of proteins, which may be an indication of cancer. For example, prostate-specific antigen (PSA) tests, are used to screen for prostate cancer in men. Medicare Part B covers PSA tests once every 12 months and will cover additional tests if you have symptoms or a cancer diagnosis.
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).
Are Routine Blood Testing Covered?
Part B also covers some routine blood tests that are used to check for health issues or monitor an existing condition. The coverage and out-of-pocket expenses for these blood tests will depend on if they are deemed medically necessary.
Some preventive blood tests that are not medically necessary and hence may not be covered by Medicare include the following:
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.
Note that you may have to pay the full cost of these blood tests if Medicare denies coverage for them. So make sure you check with your insurance provider about the exact prices and costs to you before agreeing to any testing that may not be medically necessary.
How About Medicare Advantage Plans?
What about Medicare Advantage Plans(Part C)? The good news is that diagnostic blood tests are covered by most Medicare Advantage Plans, as they are important in helping to detect diseases, manage chronic conditions, and monitor treatment plans.
Like Original Medicare, some Medicare Advantage plans will require you to obtain prior authorization from your doctor for certain blood tests. It is important to note that these plans may charge you for non-medically necessary or preventive blood screening tests. As such, you should compare different Medicare Advantage plans to find the one with the blood test coverage that best suits your needs.
How to Sign Up for a Medicare Advantage Plan?
Once you become eligible for Medicare, you can sign up for 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.
Find the Medicare Plan with the Best Blood Test Coverage
Just remember that whether you need an Original Medicare plan or a Medicare Advantage plan, there are plenty of resources available to help you sign up. At the same time, navigating between different Medicare Advantage Plans can be difficult. If blood testing coverage is important to you, you need to find one that provides the best coverage while also suiting your financial situation.
Make sure you compare factors such as cost, coverage, physician networks, and prescription drug coverage, and other benefits while selecting Medicare Advantage Plans in your area. In addition to using Medicare.gov, another good resource is to work with a medical insurance broker, who can help you compare plans and find one that best suits your needs.
