Does Medicare Pay for CT Scans? Coverage and Costs
Demystify Medicare coverage for CT scans. Learn how Original Medicare and Advantage plans affect your diagnostic imaging costs and required steps.
A computed tomography (CT) scan uses X-rays and computer processing to generate detailed cross-sectional images of the body. These scans assist medical professionals in diagnosing, monitoring, or treating various health conditions. Medicare, the federal health insurance program for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease, covers medically necessary CT scans. Coverage specifics and associated costs depend on the type of Medicare plan an individual possesses.
Coverage under Original Medicare
Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), provides coverage for CT scans when they are deemed medically necessary. Medicare Part B primarily covers outpatient diagnostic tests, including most CT scans. For coverage under Part B, a licensed physician must determine that the CT scan is needed to diagnose, monitor, or treat a medical condition.
If a CT scan is performed during an inpatient hospital stay, Medicare Part A covers the scan as part of the overall inpatient services. While Part A covers CT scans in an inpatient setting, most CT scans are typically administered on an outpatient basis and thus fall under Part B coverage. The distinction between inpatient and outpatient care significantly influences which part of Original Medicare covers the service.
Coverage through Medicare Advantage Plans
Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare and serve as an alternative to Original Medicare. By law, these plans must cover at least all the services that Original Medicare covers, including medically necessary CT scans.
Medicare Advantage plans may implement different rules and cost-sharing structures than Original Medicare. These plans often require beneficiaries to utilize in-network providers to receive full coverage for services like CT scans. Many Medicare Advantage plans also require prior authorization for certain advanced imaging procedures, including CT scans, to ensure the service is medically appropriate. Beneficiaries should understand these plan-specific requirements.
Understanding Your Costs
Out-of-pocket costs for a CT scan vary depending on whether an individual has Original Medicare or a Medicare Advantage plan. Under Original Medicare Part B, after meeting the annual deductible, beneficiaries typically pay 20% of the Medicare-approved amount for the CT scan. If the CT scan occurs in a hospital outpatient department, a copayment to the hospital may also apply in addition to the 20% coinsurance.
Medicare Advantage plans have different cost-sharing structures, which can include varying copayments, deductibles specific to the plan, and an annual out-of-pocket maximum. Some Medicare Advantage plans may offer $0 copays for in-network imaging services. Medicare Advantage plans include a yearly limit on out-of-pocket spending for covered Part A and Part B services. Once this limit is reached, the plan generally covers 100% of covered services for the remainder of the year. For those with Original Medicare, Medicare Supplement Insurance (Medigap) policies can help cover some of these out-of-pocket costs, such as the Part B deductible, coinsurance, and copayments.
Necessary Steps for Coverage
To ensure Medicare covers a CT scan, several practical steps are important for beneficiaries to follow. A doctor’s order for the CT scan is necessary for Medicare coverage. This order must establish the medical necessity of the procedure, indicating that it is required to diagnose, monitor, or treat a medical condition.
Prior authorization may be required for a CT scan, particularly for those enrolled in Medicare Advantage plans. Confirm this requirement with your plan or provider beforehand to avoid unexpected costs. Choosing a provider and facility that accept Medicare assignment is also a critical step. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment for services, which helps limit a beneficiary’s out-of-pocket expenses to deductibles and coinsurance.