An echocardiogram (echo) is a medical test that provides valuable information on the heart. Medicare usually covers the test if it is medically necessary, and if the provider accepts Medicare assignment.
Whether a person has original Medicare or Medicare Advantage, coverage for echos may involve out-of-pocket costs.
These include coinsurance, copayments, and deductibles, all of which depend on various factors, such as the type of plan or the area of the country in which a person lives.
This article examines Medicare coverage of an echocardiogram and the out-of-pocket costs. Then, it discusses echocardiograms, as well as other heart tests that Medicare may cover.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Original Medicare comprises Part A and Part B.
Medicare Advantage, also known as Part C, is the alternative to original Medicare. It must provide the same coverage as original Medicare parts A and B.
Medicare Advantage plans cover an echo in an inpatient or outpatient setting, but to keep costs down, they may require a person to use in-network providers.
Medigap plans are available to those with original Medicare but not those with Medicare Advantage plans.
Medicare Part D is prescription drug coverage. This Medicare program does not pertain to echocardiograms.
Below are some of the out-of-pocket costs for 2021, that could be associated with an echocardiogram in parts of Medicare.
If a person has an echo during a hospital stay, costs for the tests, and all other hospital services include:
- $1,484 deductible for each benefit period
- $0 coinsurance for days 1–60
- $371 coinsurance per day for days 61–90
- $742 coinsurance for each lifetime reserve day for days 91 and beyond
Someone who has an echo in an outpatient setting can expect these Part B costs:
- $148.50 monthly premium
- $203 annual deductible
- 20% coinsurance
To illustrate, the average cost of an echocardiogram without insurance is $2,000.
For this amount, and if a person has already paid their $203 deductible, Medicare will cover 80% of the $2,000, which would be $1,600. A person would be responsible for the remaining $400.
The costs for Medicare Advantage plans include deductibles, copayments, coinsurance, and monthly premiums.
All costs vary among the plans. Before having an echocardiogram, a person may wish to check with their plan provider to confirm the out-of-pocket expenses they may expect.
The test also displays:
- areas of the heart muscle that do not contract adequately due to poor blood flow or damage from an earlier heart attack
- blood clots within the heart
- problems with the aorta, the primary artery that takes blood from the heart to all parts of the body
- fluid accumulation in the sac around the heart
Doctors use an echocardiogram to:
- diagnose a condition
- decide on treatment
- watch for improvements
- determine the need for further tests
Aside from echocardiograms, Medicare covers other medically necessary heart tests. Below are some common ones.
- An electrocardiogram (ECG or EKG) indicates how well the electrical signals that control heartbeat are functioning. It shows the rate and regularity of heartbeats and provides information on the possibility of a heart attack or an abnormal heart rhythm, such as atrial fibrillation.
- A cardiac CT scan is an imaging test that shows details of the heart and blood vessels. It can help detect conditions, such as coronary artery disease, aorta problems, or calcium accumulation within arteries.
- Cardiac catheterization involves threading a tube from another part of the body to the heart. It can assist in the diagnosis and treatment of certain heart conditions.
- A stress test shows how the heart works during exercise or physical stress. It can help diagnose coronary artery disease, heart failure, and heart valve disease.
- A chest X-ray is an image of the heart, lungs, and blood vessels within the chest. It can show signs of heart failure and lung disorders.
- A cardiac MRI uses magnets, radio waves, and a computer to create pictures of the heart. It can show the presence and severity of heart disease and help determine the best treatment for conditions, such as heart valve problems and heart tumors.
- A coronary angiography looks at the inside of arteries. It shows the severity of the buildup of plaque.
The Medicare coverage and out-of-pocket costs regarding echocardiograms also apply to the above tests.
With original Medicare, Part A covers an echocardiogram a person has during a hospital stay, and Part B covers the test an individual has in an outpatient clinic.
Medicare Advantage plans also cover an echocardiogram in both inpatient and outpatient settings.
If someone with original Medicare needs extensive heart tests and treatment, they may wish to consider buying a Medigap plan to help with out-of-pocket costs.
Medigap plans are not available to people with a Medicare Advantage plan.