Echocardiograms are usually covered by Original Medicare (Parts A and B) or Medicare Advantage (Part C). Medigap can help decrease out-of-pocket costs.
Medicare will cover any medically necessary diagnostic tests you need. This includes echocardiograms.
Your exact coverage will depend on where you have the test and which Medicare part covers it.
Part A is hospital insurance. It covers the care you receive during your stay at a hospital, skilled nursing facility, or other inpatient facility.
This includes any tests your doctor orders during inpatient care. So, if you receive an echocardiogram in the hospital, Part A will cover it.
In this situation, the cost of an echocardiogram will go toward your Part A deductible. In 2024, the Part A deducible is $1,632 for each benefit period.
Once you’ve met this deductible, Part A will cover all tests and procedures during your stay, with no coinsurance costs during the first 60 days of hospitalization.
Part B is medical insurance. It covers outpatient care at multiple types of healthcare facilities.
If your healthcare professional recommends an echocardiogram during your one-time “Welcome to Medicare” preventive visit, Part B will cover it.
If you’ve already had your “Welcome to Medicare” preventive visit, Part B will only cover an echocardiogram if it’s considered medically necessary for diagnosis.
For example, your healthcare professional may order an echocardiogram if you’re experiencing chest pain or shortness of breath.
After you meet your Part B deductible — $240 in 2024 — Medicare will pay 80% of the approved cost of your echocardiogram. You’ll be responsible for the other 20%.
If you have a Medicare Advantage plan, it must cover at least as much of the cost as original Medicare. However, costs vary based on the type of plan you have.
Full coverage of echocardiogram-associated costs may require you to see a provider in your plan’s network.
The deductible and copayment or coinsurance amount will depend on your plan. Contact your insurance company beforehand to get an estimate of your potential costs.
Medigap is supplemental insurance that can cover your out-of-pocket costs from Original Medicare. This includes your Part A or B deductibles, copays, and coinsurance.
That means that Medigap can cover echocardiogram-associated costs that you would typically pay out of pocket.
Medigap plans have a monthly premium on top of your Part A or B premium. So, while you’ll pay more each month, the costs will be covered when you need a service like an echocardiogram.
Sometimes, your healthcare professional may need to obtain Medicare approval to provide a certain service, regardless of whether it’s medically necessary. This is known as prior authorization.
Although you typically do not need prior authorization for an echocardiogram covered by Parts A or B, some Medicare Advantage plans may require it. It depends on the insurance company that provides your Part C plan.
In any case, you’ll generally need to get your echocardiogram at a facility that accepts Medicare. The doctor or other healthcare professional performing the echocardiogram must also participate in Medicare.
You can search for eligible providers using the Medicare website. If they don’t accept Medicare, you may have to pay the full cost out of pocket.
Part C plans may also distinguish between in-network and out-of-network care. Sometimes, you won’t have any out-of-network coverage, even if the facility participates in Medicare.
You’ll pay a higher out-of-pocket cost for out-of-network care.
Part A will cover your echocardiogram if you have it during an inpatient hospital stay, and Part B will cover it when you have it as an outpatient. Part C will also cover an echocardiogram, but you’ll typically need to stay within your plan’s network.
If Medicare doesn’t cover your echocardiogram even though you think it should, you can file an appeal. An appeal will allow you to explain why the echocardiogram was medically necessary.