Does Medicare Part A Cover X-Rays?

Medicare, a federal health insurance program, helps millions of Americans manage their healthcare costs. Medicare’s various parts address different healthcare needs, and X-ray coverage depends on specific circumstances. This article clarifies how X-rays are covered under Medicare.

Medicare Part A Coverage for X-Rays

Medicare Part A, known as Hospital Insurance, primarily provides coverage for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health services. Generally, Part A does not cover X-rays as a standalone diagnostic service when performed in an outpatient setting. X-rays are typically included under Part A only when they are medically necessary and provided as part of a beneficiary’s overall care during a covered inpatient stay.

For instance, if a person is formally admitted to a hospital as an inpatient, any X-rays performed during that stay are covered under Part A as part of the bundled inpatient services. Similarly, X-rays might be covered if they are part of care received in a skilled nursing facility, provided the beneficiary meets the qualifying inpatient hospital stay requirement for skilled nursing care. In hospice care, X-rays necessary for proper treatment related to the terminal illness are also covered under the hospice per-diem rate.

It is important to note that if an X-ray is performed while a patient is under observation status in a hospital, even if overnight, it is usually considered an outpatient service and would not fall under Part A coverage. For inpatient hospital stays, after meeting the deductible for each benefit period, Part A covers the full cost for the first 60 days.

Medicare Part B Coverage for X-Rays

Medicare Part B, or Medical Insurance, is the primary source of coverage for most X-rays. This part of Original Medicare typically covers medically necessary outpatient diagnostic services, including X-rays prescribed by a doctor or other qualified healthcare provider. These services are covered when performed in various outpatient settings, such as a doctor’s office, freestanding clinic, urgent care center, or hospital outpatient department.

Beneficiaries with Part B usually pay an annual deductible before coverage begins. After this deductible is met, Medicare Part B generally covers 80% of the Medicare-approved amount for the X-ray, and the beneficiary is responsible for the remaining 20% coinsurance.

For example, if an X-ray has a Medicare-approved amount of $100 and the deductible has been met, Medicare would pay $80, and the beneficiary would owe $20. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment.

Medicare Advantage Plans and X-Ray Coverage

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover at least the same services as Original Medicare (Parts A and B), including medically necessary X-rays.

While Medicare Advantage plans must cover the same services, the costs and rules can vary significantly from Original Medicare. These plans may have different deductibles, copayments, or coinsurance amounts for X-rays, and they often have network restrictions. Beneficiaries enrolled in a Medicare Advantage plan should review their specific plan’s details, including the Summary of Benefits, to understand their potential out-of-pocket costs and network requirements for X-rays and other services.

Some Medicare Advantage plans may offer additional benefits not covered by Original Medicare, such as routine dental X-rays, which are generally not covered by Medicare Part A or B. These added benefits are specific to each plan and contribute to the variation in coverage options available.

Medical Necessity and Cost Considerations

For any X-ray to be covered by Medicare, it must be medically necessary and ordered by a qualified healthcare provider. Medical necessity means the service is required to diagnose or treat an illness, injury, condition, or its symptoms, meeting accepted standards of medical practice. Without a medical necessity determination, Medicare will not cover the X-ray.

Beneficiaries should always confirm with their healthcare provider that the X-ray is medically necessary for their condition. It is also advisable to ask if the provider accepts Medicare assignment for Original Medicare, or if they are in the plan’s network for Medicare Advantage, to help manage potential costs. Providers who accept Medicare assignment agree to the Medicare-approved amount as payment in full, preventing balance billing.

Before receiving an X-ray, contacting the provider’s billing office or the Medicare website/plan’s customer service can help obtain an estimate of costs and verify coverage. Understanding annual deductibles and coinsurance or copayments is important for planning healthcare expenses. Medicare does not specify a limit on the number of X-rays it covers, as long as each is medically necessary.