What Blood Tests Does Medicare Not Cover?
Staying on top of your health involves routine blood tests. These preventative tests play an important role in monitoring your wellbeing and helping to detect early signs of health issues. Blood tests are covered by Medicare if they are deemed medically necessary. The only reason Medicare would not cover a blood test is if you did not need the screening to diagnose, prevent, or treat a condition. In this guide, we’ll dive into how Medicare covers blood tests as well as the most common medical concerns that might require a blood test.
Key takeaways:
Medicare does not cover blood tests when they aren’t medically necessary.
If your doctor orders a blood test to diagnose, prevent, or treat a condition, Medicare will cover the blood test.
Understanding Medicare coverage for blood tests
Before we get into how Medicare covers blood tests, it might be useful to have a brief overview of the different Parts of Medicare.
Original Medicare includes Part A and Part B:
Part A covers services in an inpatient hospital setting
Part B covers services in an outpatient setting (doctor’s office, lab, health facility, etc)
Medicare Advantage (also called Part C) is a bundled option for health insurance, offered through private insurers. Medicare Advantage replaces Original Medicare coverage, and often also includes Part D coverage. We’ll get into how Medicare Advantage plans cover blood tests later on in the section.
Medicare Part D covers prescription drugs, including those you may need after being diagnosed with a condition as a result of a blood test.
Each Part’s role in Medicare coverage for blood tests
In most cases, Medicare Part B is responsible for covering blood tests. Medicare Part B covers screenings used to diagnose a health condition, like blood tests. If you get blood drawn in a hospital setting, skilled nursing, or hospice, Part A may cover the blood test. This could happen if you’re recovering from a procedure or if you need a blood test after an emergency hospital stay.
Medicare Advantage plans must cover the same services that Original Medicare does, but out-of-pocket costs for blood tests (including copayments and coinsurance) varies from one plan to the next. It’s important to understand your Medicare Advantage plan’s out-of-pocket costs and speak with your doctor’s billing department to know exactly what you’ll pay out of pocket for a blood test.
Blood tests won’t be covered by either Original Medicare or Medicare Advantage if they aren’t necessary.
Which blood tests Medicare covers
Medicare covers any blood test that is medically necessary to diagnose and treat a health condition. The most common diagnostic blood tests include:
Blood chemistry test, which determines calcium, glucose, and electrolyte levels to see how your organs are functioning.
Complete blood count test, which measures blood cells to see if you have blood clotting problems, immune system disorders, and other blood disorders.
Lipoprotein panel, which measures cholesterol to determine the risk of heart disease. Medicare covers this test every five years.
Thyroid-stimulating hormone test, which measures the level of the thyroid-stimulating hormone for body regulation.
There are also a number of conditions that may require blood tests for diagnosis, prevention, or treatment:
Diabetes
HIV
Hepatitis B and C
Colon, prostate, and breast cancer
Sexually transmitted infections (STIs)
If you have a high risk of developing these conditions, blood tests may be covered more frequently for you.
Blood tests Medicare does not cover
It’s important to know that Medicare won’t cover any blood test if it isn’t medically necessary. If you seek a blood test on your own, it’s unlikely you’ll get it covered. Tests not covered may include those for employment purposes, wellness screenings, or routine monitoring without medical necessity.
Blood test costs can be high. Ensure that you know exactly what you're paying ahead of time if you choose to pay for one out-of-pocket.
Other lab tests that Medicare covers
Just like blood tests, Medicare covers any medically necessary clinical diagnostic lab test if your doctor orders them. A few common lab tests include:
Urinalysis
Pap test
Fecal occult blood test
Prostate-specific antigen test
Mammogram
Pap smear
Colonoscopy
Abdominal ultrasound
How often Medicare covers the costs of these tests depends on the screening. Typically, you can get the tests covered one to two times each year. For certain conditions, like breast cancer, your doctor can order a mammogram more often, and Medicare will pay for it.
Lab tests can come with out-of-pocket costs like copays and coinsurance. Original Medicare beneficiaries can enroll in a Medicare Supplement plan to offset some of these costs.
Other frequently asked questions about blood work and Medicare coverage
Medicare coverage for diagnostic tests can be confusing. Here are some other frequently asked questions.
What lab work is not covered by Medicare?
Just like for blood tests, Medicare won’t cover any lab work if it isn’t ordered by your doctor. Situations that may occur include tests for employment purposes, screening tests without a direct medical necessity, and routine monitoring not associated with a specific diagnosis.
Does Medicare cover blood work performed during the Medicare the annual wellness exam?
Medicare covers an annual wellness exam to develop a personalized prevention plan and catch any health concerns early on. The visit is not a physical exam, nor does it include other tests. Generally, you can expect the following during an annual wellness exam:
Routine measurements (like height, weight, and blood pressure)
A review of your medical and family history
A review of your current prescriptions
Personalized health advice
Advance care planning
Your doctor can order a blood test during an annual wellness exam. Medicare will cover this blood test if it doesn’t take place during your annual wellness visit.
Everyone’s healthcare needs are different. If you need help assessing whether or not Medicare would cover a diagnostic test, our licensed Advisors are here to help. Talk to us for a free, personalized advice today by calling us at 855-900-2427 or scheduling a chat online.