Medicare

Does Medicare Cover MRI Scans?

In general, whether Medicare covers a specific procedure depends on whether one meets specific criteria and which Medicare coverage they have. The same is true of MRIs. Often MRIs are covered by Medicare; however, this is not universal. Even in circumstances where Medicare covers one’s MRI, there still may out of pocket expenses. Read on to learn when Medicare covers MRIs and to what extent.

MRI

Magnetic Resonance Imaging (MRI) is more commonly referred to as an MRI and is a handy tool for performing medical diagnoses. An MRI uses a large magnet and radio waves as a noninvasive way to scan organs, tissue, and the skeletal system. The results are high-resolution, 3D images that help diagnose injury and disease.

The cost of an MRI without insurance varies depending on the type of MRI and what body area is scanned, with estimates ranging from $400 to $12,000. It’s clear why someone would want to know if their health insurance provides MRI coverage and how much it will cost them out of pocket.

If you have Medicare, you’ll be covered if you meet specific criteria. The amount of coverage will depend on what Medicare plan you have.

What is an MRI?

There are many different reasons a doctor may order an MRI for you. An MRI can determine if soft tissues like ligaments, joints, and muscles are involved in an injury. Regarding illnesses, MRIs can detect tumors and heart disease early so treatment can start as soon as possible. In the case of Alzheimer’s Disease and dementia, MRIs can rule out other potential health concerns like a stroke or hemorrhage.

MRIs are typically used when medically necessary due to their cost, the time involved, and the fact that a skilled radiologist is required to read the results. Medicare Part B covers diagnostic tests considered medically necessary, meaning MRIs will be covered if they meet the necessary criteria.

Does Medicare Cover MRIs?

In many cases Medicare will cover MRIs, however, when and to what extent varies by plan. For example, original Medicare covers MRIs within the thresholds of their respective parts (inpatient hospital stays and outpatient care). Similarly, Part C covers them as well, though it should be noted that, like all care provided on behalf of Part C, the procedure is offered by private insurance, not medicare. Medigap overage can also aid in these procedures as well, paying for any deductibles or additional charges not covered by one’s other policies.

Original Medicare

Original Medicare is health care coverage that the United States federal government manages. Medicare Part A focuses on inpatient hospital stays and skilled nursing facility care. Part B provides insurance coverage for doctor visits, outpatient care, medical supplies, preventative services, and diagnostic testing.

Medicare Part A will cover an MRI if ordered during an inpatient hospital stay. Medicare Part B will cover MRIs that your doctor orders it as a medically necessary diagnostic test. One final criterion is that the ordering physician and the MRI facility must accept Medicare.

Medicare will pay 80% of the costs associated with an MRI if you meet their criteria and after you’ve met your deductible. If you have Supplement insurance or a Medigap plan, it may pick up some of the remaining balance.

Medicare Advantage

Medicare Advantage is synonymous with Medicare Part C. Unlike Original Medicare; the federal government does not manage Medicare Advantage plans; private companies provide it. Medicare Advantage plans must follow the rules of Medicare and provide you with at least the same coverage that Part A and Part B of Original Medicare provide. Advantage plans often include additional coverage not found in Original Medicare.

Because Original Medicare covers MRIs, Advantage plans must cover them too. Several companies manage Medicare Advantage plans, so coverage often varies. You might find that your Advantage plan pays for more than the required 80% as Original Medicare dictates. You’ll have to contact your insurance provider to find out what your plan covers.

Medigap/Medicare Supplement

A Medicare Supplement insurance is often referred to as Medigap because it fills in with coverage where Original Medicare leaves gaps. The official name of this type of insurance is Medicare Supplement insurance, and it’s precisely the same as Medigap; Medigap is just a nickname.

Private insurance companies run Medigap and Medicare Supplement insurance and must follow federal and state laws. They are only available to people who have Original Medicare. If you have a Medicare Advantage plan, it’s illegal for someone to sell you a Medicare Supplement policy.

If you have Original Medicare, your Part A and Part B insurance will first determine the eligibility of the charges and pay their portion with the remaining balance going to you. If you have a Medicare Supplement, you can submit the bills to them, and they will pay a portion or all of the outstanding bills. Each plan is different, so you’ll have to check for specific coverage. This is true with MRIs also; your plan may pick up all or part of the balance, depending on your policy.

In some cases, MRIs require prescription drugs. Doctors often prescribe anti-anxiety medications if the patient is very anxious about the procedure, has claustrophobia, or cannot lie still for the entire scan. Medicare Part A and Part B do not cover prescription drugs, so they will not pay for the medication.

Medicare Part D covers prescription drugs, but independent insurance companies manage these plans, so coverage will vary. If you have a Medicare Advantage plan, you do not need to sign up for Part D. Medicare Part D is a recommended insurance if you want prescription drug coverage; it’s not required for people with Original Medicare but recommended.

Does Medicare Cover Additional Diagnostic Scans?

An MRI is not the only diagnostic nonlaboratory test your doctor may recommend; a handful of diagnostic scans are valuable tools for examining injuries and illnesses. Some of the following scans might be used instead of, or in conjunction with, an MRI.

CT Scans

CT scans and CAT scans are the same diagnostic scan. A CT scan stands for computed tomography, while a CAT scan is an abbreviation for computed axial tomography. This test produces a cross-section of your body in “thin slices” so your medical team can view one area in great detail.

CT scan machines rotate around you to create 3D imaging. The images a CT scan produces are a form of X-ray, not the magnetic imaging that an MRI uses.

CT scans are more cost-effective than MRIs, so they are often the first option, if possible. Original Medicare does cover medically necessary CT scans, which means any Medicare Advantage plan will also cover this diagnostic test.

EKGs

EKG is the abbreviation for electrocardiogram, sometimes referred to as an ECG. These diagnostic tests measure the electrical activity of your heartbeat. An EKG is a relatively simple and painless technique for diagnosing heart problems. They can detect:

  • Irregular heart rhythms
  • Blocked or narrowed arteries
  • If you’ve had a previous heart attack
  • How heart disease treatments are working (used to review pacemakers)

Medicare Part B covers EKGs when used as a diagnostic test if determined to be medically necessary. They also cover a one-time EKG as part of your initial Welcome to Medicare preventative visit. Their payment will be the standard 80%, leaving you or your Supplemental insurance to cover the remainder.

Medicare Advantage covers EKGs at 80% or more, keeping with the requirements of Medicare.

X-rays

X-rays as diagnostic tools have become very common and are something most people experience at least once in their lives. X-rays or radiography uses a type of electromagnetic wave or radiation to take a picture of the body’s internal structures. They’re excellent tools for detecting broken bones and can be used to diagnose other injuries and ailments, too.

Medicare Part B covers medically necessary x-rays at 80% after you’ve met your deductible. Any Supplemental insurance you have may cover the remaining 20%. If you have Medicare Advantage, x-rays are also covered at 80% or more, depending on your policy.

PET Scans

A PET scan is a positron emission tomography scan, a diagnostic imaging test used to review tissues and organs’ metabolic or biochemical functions. A PET scan uses a radioactive drug that collects in the body in areas with higher metabolic activity. These tests detect or monitor cancer, heart disease, and brain disorders.

If you have a PET scan as part of an inpatient hospital stay, then your Medicare Part A will cover it. Original Medicare Part B will cover it if it’s part of an outpatient diagnostic or treatment plan deemed medically necessary. Again, this type of imaging is covered at 80% by Medicare after you’ve met your deductible. Medicare Advantage will cover the same amount or more, based on your policy provisions.

What Do MRIs Cost?

The cost of an MRI, according to GoodRx Health, can range from $400 to $12,000, with the average for people without insurance costing around $2000. This number is tough to pinpoint because many variables can affect the price. For example:

  • Type of health insurance
  • In or out-of-network providers
  • Type of MRI
  • The area of the body scanned
  • Where you live
  • Additional medication needed
  • Radiologist fees
  • Other doctor fees

You can better understand your coverage by visiting the Centers for Medicare & Medicaid Services website to look up your MRI by procedure code.

Ask your healthcare provider or billing department what procedure they’re doing and the cost for a more specific answer. Medicare pays 80% of all qualifying MRIs, leaving you with the remaining 20%. They may pick up part or all of the balance if you have a Medicare Supplement plan. If you have a Medicare Advantage plan, they will pay at least 80% of the charges. Some Medicare Advantage plans pay more than the required 80%.