Will Medicare Cover Your Appointment/Procedure?

To prevent unexpected costs, it is important to know whether Medicare will cover your appointment or procedure. Coverage depends on various factors, including type of Medicare plan you have and the specific services needed. Here's how you can determine if Medicare will cover your appointment/procedure.

First, identify your Medicare coverage type. Medicare coverage varies based on the type of plan you are enrolled in. Original Medicare (Parts A and B) covers hospital stays, skilled nursing care, doctor visits, outpatient services, and preventative care. Medicare Advantage (Part C) offers coverage through private insurance companies and may include additional benefits such as vision and dental. Medicare Part D covers prescription medications. Lastly, Medicare Supplement (Medigap) helps cover out-of-pocket costs not paid by Original Medicare. Knowing which plan you have will help determine what services are covered and what costs you might be responsible for.

Check Medicare's Coverage Guidelines. Medicare covers services that are considered medically necessary and fall within in its guidelines.  To verify, use the Medicare.gov website and search for the procedure or service in the "What's Covered" tool. You can also review the Medicare & You handbook, which you receive each year as a Medicare beneficiary. This handbook details covered services. Additionally, you can speak directly with a Medicare representative at 1-800-MEDICARE (1-800-633-4227) to ask about specific coverage.

Confirm with your provider. Before scheduling an appointment or procedure, contact your healthcare provider to ensure they they accept Medicare and check if they participate in Medicare Assignment. Participating providers accept Medicare and agree to Medicare-approved pricing. Non-participating providers may charge more than Medicare's approved amount, leading to higher out-of-pocket costs. Opt-Out providers do not accept Medicare, meaning you are responsible for full payment.

Obtain Prior Authorization (if required). Some services, especially those provided under Medicare Advantage plans, require prior authorization before Medicare will cover them. Your provider should assist with obtaining necessary approvals.

Understand costs and coverage limits. Even if Medicare covers a service, you may have costs such as deductibles, copayments or coinsurance, out-of-pocket limits (for Medicare Advantage plans).

Verifying Medicare coverage before an appointment or procedure can save you from unexpected expenses. By understanding your plan, checking Medicare's coverage rules, consulting your provider, and ensuring proper authorizations, you can confidently navigate your healthcare options. If in doubt, reach out to Medicare or your insurance provider for clarification.

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​Rob Davies
Prairie Grove Insurance
800-254-5200
​608-839-0275