Quick Answer
Medicare covers the A1C blood test once every 3 months for most people with diabetes. If you have diabetes and are on intensive insulin therapy, Medicare will cover the A1C test once per month. Your doctor will determine how often you need the A1C test based on your individual condition.
What is the A1C Test?
The A1C test, also known as the hemoglobin A1C or glycohemoglobin test, is a blood test that provides information about your average levels of blood sugar over the past 3 months. It measures the percentage of hemoglobin in your blood that has glucose attached to it.
Hemoglobin is a protein in your red blood cells that carries oxygen. When you have higher blood sugar levels, more glucose circulates in your blood and binds to hemoglobin. The A1C test result reflects your average blood sugar level over the past 2 to 3 months.
Why Test A1C
The A1C test is used to:
- Diagnose type 1 and type 2 diabetes – An A1C of 6.5% or higher indicates diabetes on two separate tests
- Monitor how well your diabetes treatment plan is working
- Help adjust medications or treatment plans aim at better blood sugar control
- Look for signs of increased risk for complications from uncontrolled diabetes
By tracking your A1C results over time, you and your doctor can see how well your treatment plan is working to keep your blood sugar in your target range.
How Often is A1C Testing Covered by Medicare?
If you have been diagnosed with diabetes, Medicare covers A1C testing at the following frequencies:
- Once every 3 months – This is the standard testing frequency covered for most people with diabetes to monitor blood sugar control.
- Once per month – For people with diabetes who are on intensive insulin therapy, meaning 3 or more insulin injections per day or insulin pump therapy.
- Up to 2 times per year – For people at risk for diabetes but who have not been diagnosed with diabetes yet. This includes people with prediabetes.
Your doctor will determine and order the appropriate testing frequency for you based on your individual condition and treatment plan.
Medicare Coverage for A1C Testing
Original Medicare covers A1C testing when medically necessary and ordered by a doctor treating your diabetes. This includes:
- Part B covers A1C tests performed in a lab setting.
- Part B also covers A1C tests performed with a kit or device in your doctor’s office.
If you are in Medicare Advantage, your plan must cover A1C testing at least at the frequencies noted above. Many Medicare Advantage plans offer expanded coverage for A1C testing beyond original Medicare.
What Changes the Frequency of A1C Testing?
Here are some situations where your doctor may order the A1C test more or less often than the standard Medicare coverage:
Reasons for More Frequent A1C Testing
- You have newly diagnosed diabetes – Frequent testing may be needed to help establish an effective treatment plan.
- You changed your treatment plan – Testing may be needed more often to ensure your blood sugar levels are on target.
- Your blood sugar is poorly controlled or unstable
- You are pregnant – Tighter control of blood sugar is needed during pregnancy to reduce risks.
- You have an acute illness – Blood sugar fluctuations are common.
Reasons for Less Frequent A1C Testing
- Your blood sugar has been consistently well controlled for some time – Your doctor may reduce testing frequency.
- You have certain medical conditions that interfere with the accuracy of A1C test results.
Your doctor will assess your individual situation and determine the optimal frequency for testing your A1C level.
What is a Normal A1C Level?
The goal A1C level for most people with diabetes is under 7%. The higher your A1C result, the higher your average blood sugar levels have been over the past 2 to 3 months.
| A1C Level | Average Blood Sugar |
|---|---|
| Normal (without diabetes) | Less than 5.7% |
| Prediabetes | 5.7% to 6.4% |
| Diabetes | 6.5% or higher |
| Good control of diabetes | Less than 7% |
As shown in the table, a normal A1C for someone without diabetes is less than 5.7%. A level of 6.5% or higher indicates diabetes on repeated testing. For people with diabetes, keeping your A1C under 7% is associated with reduced risk of complications.
Does Medicare Cover the Cost of the A1C Test?
Yes, Medicare covers the cost of the A1C test when medically necessary and ordered by your treating doctor.
- For Original Medicare – Part B covers 100% of the Medicare-approved cost when performed in a lab setting or doctor’s office.
- For Medicare Advantage – Copays and costs vary by plan. Many plans offer $0 copays for covered lab services.
With both Original Medicare and Medicare Advantage, you pay nothing for the A1C test itself when it is covered. However, you may be responsible for part of the costs for:
- The office visit fee if your doctor collects a blood sample and sends it to a lab for testing.
- The contracted rate for your lab if not in your plan’s network.
Talk to your Medicare plan to understand the costs specific to your coverage and lab options in your area.
Out-of-Pocket Costs
While Medicare covers the A1C test itself, you may have certain out-of-pocket costs:
- Medicare Part B deductible – $226 in 2023. Applies if your doctor bills Medicare directly for the test.
- Copay for the doctor visit to collect the blood sample if required by your plan.
- Coinsurance for the lab test if performed by a non-contracted lab.
- Part B excess charges if using a doctor or lab that does not accept Medicare assignment.
Tip: Ask your doctor to use a lab in your plan’s network to minimize your out-of-pocket costs.
Steps to Get an A1C Test Covered by Medicare
Follow these steps:
- Schedule an appointment with your doctor – This provides the order for your A1C testing.
- Have your blood drawn at your doctor’s office or at a participating lab.
- Your blood sample will be analyzed and your A1C percentage will be calculated.
- Your doctor will receive the results and explain what your A1C means.
- The lab will handle billing Medicare on your behalf.
- You will receive a Medicare Summary Notice explaining covered charges and any costs you may owe.
Be sure Medicare has your current address so you receive your notices promptly. Reach out to the billing lab directly with any questions about your notice.
Appealing Denied Coverage
If Medicare denies coverage for your A1C testing, you have the right to file an appeal:
- Review the reason for the denial in your Medicare Summary Notice.
- Contact your doctor and ask their office to file a coverage appeal on your behalf.
- Submit any necessary medical records and documentation your doctor recommends to support medical need.
- You can appoint a friend, relative or advocate to assist you with the appeals process.
- If your first appeal is unsuccessful, you can take your appeal through levels including an Administrative Law Judge hearing.
Having your doctor provide evidence and justification for testing frequency is key for a successful appeal.
A1C Test Provides Vital Information for Diabetes Care
The A1C blood test provides you and your healthcare providers with crucial information about your average blood sugar over time. This helps guide treatment decisions to keep your diabetes under control and avoid risks from elevated blood sugar levels.
Medicare provides coverage for this important test to support you in effectively managing your diabetes. Be sure to stay up-to-date with testing at the frequency recommended by your doctor. Monitoring your A1C trends over time can help you achieve positive health outcomes.