Medicare Coverage of a Nurse Practitioner
What It Is
Medical care provided by a nurse practitioner
Medicare Part B covers care provided by a nurse practitioner at a doctor's office, clinic, or hospital outpatient department, if the nurse practitioner is Medicare-certified and the service provided is within the proper scope of the nurse practitioner's practice.
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 care provided by a nurse practitioner, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for a nurse practitioner's services.
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.