Does Medicare Cover the Hemoglobin A1c Test?

The Hemoglobin A1c (A1c) test is a blood test that measures average blood sugar levels over the past two to three months. It is used to identify prediabetes, diagnose type 2 diabetes, and monitor blood sugar control. Medicare generally covers this test for eligible beneficiaries.

Medicare Coverage Basics for A1c

Medicare Part B covers medically necessary A1c tests. Medicare expanded coverage to include the A1c test for screening, in addition to its use for monitoring diagnosed diabetes.

For screening, Medicare Part B covers up to two A1c tests annually for beneficiaries at risk for type 2 diabetes. Risk factors include high blood pressure, elevated cholesterol or triglyceride levels, a history of high blood sugar, obesity, age 65 or older, a family history of diabetes, or a history of gestational diabetes.

For diagnosed individuals, Medicare Part B covers the A1c test for monitoring, typically every 90 days or more frequently if medically necessary. A doctor’s order is required for coverage. Medicare Advantage Plans (Part C) must cover A1c tests, but may have different rules regarding how services are accessed, such as requiring network providers. Medicare Part D covers prescription drugs and does not cover diagnostic tests like the A1c.

Understanding Your Costs

Under Original Medicare Part B, the cost-sharing for the A1c test varies based on whether it is for screening or diagnostic purposes. When performed as a screening service for those at risk or with prediabetes, it is typically covered as a preventive service. This means beneficiaries generally pay no Part B coinsurance or deductible if the provider accepts Medicare assignment.

If the A1c test is used for diagnostic purposes or to monitor already diagnosed diabetes, the standard Part B cost-sharing rules apply. In this scenario, beneficiaries are responsible for the annual Part B deductible. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount, and the beneficiary is responsible for the remaining 20% coinsurance. Medicare Advantage Plans may have different cost-sharing structures, such as copayments or coinsurance amounts, so it is advisable for beneficiaries to review their specific plan details to understand potential out-of-pocket expenses. Medigap policies, also known as Medicare Supplement Insurance, can help cover the Part B deductible and the 20% coinsurance that Original Medicare does not pay, thereby reducing a beneficiary’s out-of-pocket costs for covered A1c tests.

Accessing the Test and Your Results

To obtain an A1c test covered by Medicare, the initial step involves consulting with your healthcare provider. Your doctor will determine if the test is medically necessary based on your health status and risk factors, then provide the necessary order or referral. This ensures the test aligns with Medicare’s coverage criteria.

The A1c test can be performed in various settings, including your doctor’s office, an independent laboratory, or a hospital outpatient department. It is important to confirm that the provider and facility accept Medicare assignment to ensure proper coverage and minimize your out-of-pocket costs. The testing procedure itself is straightforward, involving a simple blood draw from a vein in your arm or, in some cases, a finger prick. A significant advantage of the A1c test is that it does not require fasting beforehand.

Once your blood sample is collected, it is sent to a laboratory for analysis. The results are typically sent to your ordering physician. While some in-office labs may provide results on the same day, results from external laboratories are usually available within a few days to about a week. After receiving your results, your doctor will discuss the findings with you, explain their meaning, and recommend any necessary follow-up care or lifestyle adjustments to manage your blood sugar levels effectively.