High cholesterol is a major risk factor for heart disease and stroke. Medicare recognizes the importance of monitoring and controlling cholesterol levels, which is why coverage is provided for cholesterol screening tests. However, Medicare does place limits on how often these screening tests will be covered.
What is cholesterol screening?
Cholesterol screening involves drawing blood to measure the levels of total cholesterol, LDL (“bad”) cholesterol, HDL (“good”) cholesterol, and triglycerides. This allows your doctor to assess your risk for cardiovascular disease and determine if medication or lifestyle changes are needed to manage cholesterol levels.
Standard cholesterol screening tests include:
- Lipid panel – Measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides
- Apolipoprotein B test – Measures particles associated with LDL cholesterol
- Lipoprotein (a) test – Measures particles associated with heart disease and stroke risk
Who needs cholesterol screening?
The U.S. Preventive Services Task Force recommends the following for cholesterol screening in adults:
- Men aged 35 years and older should be screened.
- Women aged 45 years and older should be screened if they are at increased risk for coronary heart disease. This includes women with cardiovascular risk factors such as smoking, obesity, inactivity, diabetes, hypertension, or family history.
- Younger adults should be screened if they have other risk factors for coronary heart disease.
Based on your age, risk factors, and cholesterol test results, your doctor will make recommendations on how often follow-up testing is needed.
How often does Medicare cover cholesterol screening?
Original Medicare covers cholesterol screening every 5 years.
This means you can get a lipid panel or other cholesterol test once every 5 years and Medicare Part B will cover it, provided your doctor determines the test is medically necessary.
In general, Medicare covers cholesterol screening at these frequencies:
- Low risk: Once every 5 years
- Moderate risk: Once every 2 years
- High risk: Once per year
However, if you have certain medical conditions, Medicare may cover cholesterol tests more often:
- Diabetes: Covered up to 4 times per year if you have diabetes
- Heart disease: Covered twice per year if you have heart disease, heart failure, or heart valve problems
- Hyperlipidemia: Covered up to 4 times per year if you have hyperlipidemia (high cholesterol or triglyceride levels)
- Obesity: Covered twice per year if you are obese
- Kidney disease: Covered up to 6 times per year if you have chronic kidney disease
Talk to your doctor about your specific risk factors to determine if more frequent cholesterol testing is recommended in your case.
Does Medicare cover repeat testing after starting statin therapy?
Yes, in some cases Medicare will cover repeat cholesterol testing after you begin taking statins or other cholesterol lowering medications. This allows your doctor to monitor your response to therapy.
Medicare typically covers repeat testing in these situations:
- 3 months after starting or changing dose of statin medication
- Annually, if cholesterol levels were abnormal at last test
- Every 2 years, if cholesterol levels were normal at last test
Your doctors may also recommend more frequent testing after starting statins based on your cardiovascular risk factors.
When does Medicare not cover cholesterol screening?
In some cases, Medicare may determine that cholesterol screening is not reasonable and necessary:
- If testing is done solely for your own purposes or interest, but is not medically required
- If testing is ordered more frequently than Medicare guidelines allow
- If you have end-stage renal disease (ESRD) and are not undergoing dialysis
Medicare also does not cover cholesterol screening during certain windows around procedures. For example, testing is not covered within 14 days before or after surgery.
Talk to your provider about the medical necessity requirements for cholesterol screening to ensure services will be covered.
How much does Medicare pay for cholesterol testing?
If you have Original Medicare Part B, you will pay:
- A Part B deductible for your first claim – $226 in 2023
- 20% coinsurance for cholesterol testing after the deductible is met
Here are the 2023 Medicare reimbursement rates for common cholesterol tests:
| Test | Medicare National Limit |
|---|---|
| Lipid panel | $14.79 |
| Lipoprotein, blood; electrophoretic separation and quantitation | $16.94 |
| Lipoprotein blood test, direct measurement | $17.25 |
| Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins | $32.57 |
If you have a Medicare Advantage plan, copays and coinsurance amounts may vary depending on the plan.
Can I get cholesterol testing more often if I pay out-of-pocket?
Yes, Medicare will still cover medically necessary cholesterol screening at the frequencies outlined, even if you choose to pay for additional testing out-of-pocket.
For example, if you are at high risk for heart disease, Medicare may only cover annual cholesterol testing. But you have the option to pay out-of-pocket for additional testing every 6 months. Just be aware that Medicare will not reimburse you for these additional tests that exceed coverage limits.
Before paying for extra testing, discuss the benefits and risks with your provider to make sure it is medically advisable in your situation.
Should I get cholesterol testing during my Annual Wellness Visit?
Your Annual Wellness Visit (AWV) is a great time to discuss cholesterol screening with your primary care provider. They can assess your risk factors and determine if testing is due based on Medicare coverage guidelines.
Medicare covers the AWV once every 12 months. It is focused on disease prevention and health promotion. During the visit, your provider may:
- Review your medical and family history
- Develop a list of current providers and prescriptions
- Check your height, weight, blood pressure, and other routine measurements
- Screen for cognitive impairment
- Provide personalized health advice
- Order tests like cholesterol screening as needed
The AWV does not include a full physical exam. But it allows your provider time to focus on prevention and recommend appropriate testing based on your health status.
What do my cholesterol test results mean?
Knowing your cholesterol levels is important, but understanding what those numbers mean is essential. Here is what your test results indicate:
- Total cholesterol – Levels below 200 mg/dL are desirable. 200-239 mg/dL is borderline high. Over 240 mg/dL is considered high.
- LDL cholesterol – LDL carries cholesterol to your arteries. Below 100 mg/dL is optimal. Near or above 190 mg/dL is very high.
- HDL cholesterol – HDL removes cholesterol from your arteries. Levels of 60 mg/dL and above are protective.
- Triglycerides – Ideal levels are below 150 mg/dL. High triglycerides increase your heart disease risk.
Your doctor will look at your total cholesterol, LDL, HDL, triglycerides, and other risk factors like blood pressure and smoking status to determine your overall heart disease risk. This guides advice on lifestyle changes and medication to optimize cholesterol levels.
How can I lower my cholesterol between screening tests?
To lower cholesterol between screening tests, focus on heart-healthy lifestyle changes like:
- Following a diet low in saturated and trans fat. Eat plenty of fruits, vegetables, whole grains, beans, fish, and low-fat or fat-free dairy.
- Exercising for 30 minutes most days of the week
- Reaching and maintaining a healthy body weight
- Quitting smoking and limiting alcohol
Medication may also be needed to reach target cholesterol levels in many cases. Talk to your doctor about whether statins, bile acid sequestrants, cholesterol absorption inhibitors, fibric acid derivatives, or other medications should be part of your treatment plan.
Does Medicare cover cholesterol testing supplies?
Medicare Part B covers the medical equipment needed to perform covered cholesterol screening tests, including:
- Needles, syringes, and tubes required to draw blood
- Lancets and test strips if a fingerstick method is used
- Reagents and control materials needed to analyze the blood sample
This means you do not need to pay extra for the supplies used to collect and test your blood during your covered cholesterol screening. The cost is included as part of the lab test charge.
Should I fast before cholesterol testing?
Current guidelines say fasting is not required before cholesterol testing. But your doctor may recommend fasting for 9-12 hours before your blood draw if any of the following apply:
- You have diabetes or another condition that affects triglyceride levels
- You are going to have advanced lipoprotein testing beyond a standard lipid panel
- Your doctor prefers fasting samples for increased consistency
Talk to your healthcare provider about whether fasting is recommended prior to your cholesterol test.
Does Medicare cover cholesterol testing at home or at a lab?
Medicare covers cholesterol testing by both in-home and laboratory providers, as long as the supplier is enrolled in Medicare.
Home health agencies can perform covered cholesterol screening in your home if you meet Medicare home health eligibility criteria. You must be homebound and under the care of a doctor.
You also have the option to visit an in-network lab like Quest Diagnostics or LabCorp. Ask your provider which lab they use for samples when they order your test.
What if my cholesterol test is not covered?
If Medicare determines that your cholesterol screening test does not meet medical necessity guidelines, you have a few options:
- Appeal – You have the right to appeal denials and demonstrate that the test was reasonable and necessary for your condition.
- Pay out-of-pocket – You can choose to pay the full cost of the test yourself.
- Find free testing – Some locations like health clinics or community centers offer free or low-cost cholesterol testing.
Before paying for a test yourself, consider whether the timing aligns with clinical guidelines or if your doctor could provide documentation to appeal a denial.
Can I get cholesterol testing more often with a Medicare Advantage Plan?
Original Medicare covers preventive cholesterol screening every 5 years, or more often depending on your cardiovascular risk factors. Medicare Advantage plans must cover screenings at least to this minimum frequency.
Some Medicare Advantage plans offer enhanced preventive benefits, including more frequent cholesterol testing. For example, a plan may cover screening every 2 years instead of every 5 years.
Before enrolling in a Medicare Advantage plan, review the details of covered preventive services. This will tell you if cholesterol testing is covered more often than with Original Medicare.
Conclusion
Medicare covers cholesterol screening to monitor heart disease risk, but places limits on testing frequency. In general, screening is covered every 5 years. But people with conditions like diabetes, heart disease, and obesity can qualify for testing 2-4 times per year.
Talk to your doctor about your personal risk factors for high cholesterol. They can recommend appropriate screening frequency and help interpret your cholesterol test results. Maintaining healthy levels reduces your chances of developing cardiovascular disease.