Eligibility Rules
Many preventive services are covered only if you meet Medicare’s eligibility rules. These rules can include your age, risk factors, medical history, lab results, diagnoses, or timing (for example, being “at risk” for a screening).
Why it Matters
If you don’t meet the eligibility criteria, Medicare may not cover the service as a preventive benefit. That can mean the service is denied, or it’s covered under different rules with cost-sharing.
Action Steps
Ask: “Do I meet Medicare’s eligibility criteria for this screening or counseling?”
Bring key details to appointments (smoking history, family history, diagnoses, recent labs).
If you’re on Medicare Advantage, confirm requirements with your plan (some plans add steps).
If coverage is denied, ask for the reason and whether an alternative covered option exists.