Medicare Coverage of Clinic Care or Health Center Care
What It Is
Outpatient care from a clinic or health center
Medicare Part B covers all medically necessary outpatient care, including laboratory and diagnostic testing, provided by a freestanding clinic or health center. This is true whether the actual care is provided by a physician, nurse practitioner, or other qualified medical personnel. However, in order for Medicare Part B to cover the care, the clinic or health center must be Medicare-certified.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for clinic care or health center care, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for care provided by a clinic or health center.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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