How to Find Medicare Coverage for Lungs

Navigating Medicare to secure comprehensive coverage for lung conditions can feel like a complex puzzle. With various parts, supplementary plans, and specific rules for different services, understanding what’s covered and how to maximize your benefits is crucial for managing lung health. This in-depth guide provides clear, actionable steps to help you find and utilize Medicare coverage for your lungs, from preventive care to managing chronic conditions and acute illnesses.

Decoding Medicare’s Structure for Lung Health

Medicare, the federal health insurance program for people 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), is divided into several parts, each covering different aspects of your healthcare. Understanding these parts is the first step in finding coverage for your lungs.

Medicare Part A: Hospital Insurance for Lung Care

Part A primarily covers inpatient hospital stays. This is critical if you need hospitalization for severe lung infections like pneumonia, acute exacerbations of chronic obstructive pulmonary disease (COPD), or lung cancer surgery.

What Part A Covers (Examples):

Inpatient Hospital Stays: If you’re admitted to a hospital for acute pneumonia requiring intravenous antibiotics and respiratory support, Part A covers your hospital room, nursing services, meals, and other hospital services.
Skilled Nursing Facility (SNF) Care: Following a hospital stay for a lung condition, if you need continued skilled nursing care or rehabilitation for breathing exercises and lung function improvement, Part A can cover a limited period in an SNF. For example, after major lung surgery, you might need a short stay in an SNF for physical therapy and respiratory therapy.
Hospice Care: For individuals with a terminal lung illness, such as end-stage COPD or advanced lung cancer, Part A covers hospice care, focusing on comfort and pain management rather than curative treatment. This can include services in your home or in an inpatient hospice facility.
Home Health Care (Limited): If you’re homebound and need intermittent skilled nursing care or therapy services for a lung condition (e.g., a nurse administering IV antibiotics for a lung infection, or a physical therapist teaching breathing exercises after a lung illness), Part A may cover these.

Actionable Tip: Always ensure your admission is formally recorded as an “inpatient” stay. If you’re under “observation status” in a hospital, even for several days, it’s considered an outpatient service and falls under Part B, which can lead to different costs. Ask the hospital staff about your admission status to avoid surprises.

Medicare Part B: Medical Insurance for Outpatient Lung Services

Part B covers medically necessary services from doctors and other healthcare providers, outpatient care, durable medical equipment (DME), and some preventive services. This is where most of your routine lung care will fall.

What Part B Covers (Examples):

Doctor’s Visits: Appointments with pulmonologists, primary care physicians, and other specialists for diagnosis, treatment, and management of lung conditions like asthma, COPD, or interstitial lung disease. For instance, regular check-ups with your pulmonologist to monitor your COPD and adjust medication.
Outpatient Hospital Services: Emergency room visits for breathing difficulties (if not leading to inpatient admission), diagnostic tests performed in a hospital outpatient setting (e.g., chest X-rays, CT scans, pulmonary function tests).
Durable Medical Equipment (DME): This includes oxygen equipment, nebulizers, continuous positive airway pressure (CPAP) machines for sleep apnea, and other respiratory devices prescribed by your doctor for home use. Medicare Part B typically pays 80% of the Medicare-approved amount, and you pay the remaining 20% after meeting your deductible. For example, if you need a home oxygen concentrator due to severe COPD, Part B covers most of the cost.
Pulmonary Rehabilitation: This comprehensive program includes exercise training, education on lung disease management, and counseling for people with moderate to very severe COPD, or those with persistent respiratory dysfunction after confirmed or suspected COVID-19. Medicare covers up to 36 sessions, with the possibility of more if medically necessary. You’ll typically pay 20% of the Medicare-approved amount.
Diagnostic Tests: Blood tests, sputum tests, biopsies, and other laboratory tests ordered by your doctor to diagnose or monitor lung conditions. For instance, a lung biopsy to diagnose lung cancer.
Lung Cancer Screening: Medicare covers annual low-dose computed tomography (LDCT) lung cancer screening for eligible individuals aged 50-77 with a 20 pack-year smoking history who currently smoke or have quit within the last 15 years. This screening is covered without cost-sharing if specific criteria are met and a shared decision-making visit with your doctor precedes it.
Certain Vaccinations: Pneumococcal vaccines (pneumonia shots) and flu shots are covered under Part B to protect against common respiratory infections.
Outpatient Prescription Drugs (Limited): Part B covers a limited number of outpatient prescription drugs, primarily those you wouldn’t typically self-administer, such as certain infused or injectable drugs administered in a doctor’s office or hospital outpatient setting (e.g., certain medications for pulmonary hypertension).

Actionable Tip: Ensure your doctor “accepts assignment” when you receive Part B services. This means they agree to accept the Medicare-approved amount as full payment, limiting your out-of-pocket costs to the deductible and coinsurance. You can find providers who accept Medicare assignment on the official Medicare website’s physician compare tool.

Medicare Part C (Medicare Advantage): An All-in-One Alternative for Lung Care

Medicare Part C, known as Medicare Advantage (MA), is offered by private insurance companies approved by Medicare. These plans combine Part A and Part B coverage and often include Part D (prescription drug) coverage, plus additional benefits that Original Medicare doesn’t cover.

How Part C Works for Lung Conditions (Examples):

Bundled Benefits: Instead of separate Part A, Part B, and Part D, your MA plan covers all these aspects. If you have COPD, your MA plan would cover your hospital stays (Part A), pulmonologist visits and oxygen equipment (Part B), and your inhalers (Part D) under one plan.
Additional Benefits: Many MA plans offer extra benefits useful for lung health, such as routine dental, vision, and hearing care, fitness programs (which can aid lung function), and sometimes even over-the-counter allowances for health products. Some plans also offer disease management programs specifically for chronic conditions like COPD or asthma.
Special Needs Plans (SNPs): If you have specific chronic conditions, such as chronic lung disorders (e.g., severe COPD, pulmonary fibrosis), you might qualify for a Chronic Condition Special Needs Plan (C-SNP). These plans are tailored to provide specific benefits and care coordination for your condition, potentially offering integrated care teams and specialized services. For example, a C-SNP might offer a dedicated care manager who helps coordinate your appointments, medications, and home health services for severe emphysema.
Network Restrictions: MA plans often have provider networks (HMOs or PPOs). You may need to use doctors and hospitals within the plan’s network to get the most coverage. If you have a long-standing relationship with a pulmonologist, verify they are in the network of any MA plan you consider.
Out-of-Pocket Maximums: Unlike Original Medicare, MA plans have an annual out-of-pocket maximum, which limits how much you’ll pay for covered services in a year. Once you reach this limit, your plan pays 100% of covered healthcare costs for the rest of the year, offering greater financial predictability.

Actionable Tip: Carefully compare MA plans available in your area. Look at the plan’s formulary (list of covered drugs) to ensure your lung medications are included, and check the provider directory to see if your current pulmonologist and other specialists are in-network. Pay attention to deductibles, copayments, and coinsurance amounts for services related to lung care.

Medicare Part D: Prescription Drug Coverage for Lung Medications

Medicare Part D is standalone prescription drug coverage offered by private insurance companies approved by Medicare. If you have Original Medicare (Parts A and B), you’ll likely need to enroll in a separate Part D plan to cover your medications. Most Medicare Advantage plans already include Part D coverage.

What Part D Covers (Examples):

Inhalers: Maintenance inhalers for asthma and COPD (e.g., bronchodilators, corticosteroids), and rescue inhalers (e.g., albuterol).
Oral Medications: Pills for lung conditions, such as oral steroids for acute asthma exacerbations, antibiotics for lung infections, or specific medications for pulmonary hypertension.
Nebulized Medications: Medications administered via a nebulizer (though the nebulizer device itself is covered under Part B).
Immunosuppressants: If you’ve had a lung transplant and Medicare helped pay for the transplant, Part B generally covers immunosuppressive drugs. However, if Medicare did not help pay for the transplant, these drugs would fall under Part D.

Actionable Tip: Each Part D plan has a “formulary,” which is a list of covered drugs. This formulary can change annually. When choosing a Part D plan, check its formulary to ensure all your current and anticipated lung medications are covered and at what cost-sharing tier. Generic medications are typically in lower tiers with lower copayments, while brand-name drugs are in higher tiers and cost more.

Supplementing Original Medicare: Medigap Policies

If you have Original Medicare (Parts A and B), you’re responsible for deductibles, copayments, and coinsurance. These out-of-pocket costs can add up, especially with chronic lung conditions requiring frequent care. Medigap policies (Medicare Supplement Insurance) are sold by private companies to help pay some of these costs.

How Medigap Helps with Lung Costs (Examples):

Part A Deductible and Coinsurance: Covers the inpatient hospital deductible ($1,676 per benefit period in 2025) and coinsurance for extended hospital stays beyond what Part A covers. This is highly beneficial if you require prolonged hospitalization for severe pneumonia or lung failure.
Part B Coinsurance and Deductible: Covers the 20% coinsurance for most Part B services and, depending on the plan, the Part B deductible ($257 in 2025). This is invaluable for ongoing pulmonologist visits, pulmonary rehabilitation sessions, and DME costs. For example, if your oxygen concentrator costs $1000 and Medicare pays $800, your Medigap plan could cover the remaining $200.
Part B Excess Charges: Some Medigap plans (Plans F and G) cover “excess charges,” which are amounts above Medicare’s approved amount that some doctors are permitted to charge. This ensures you won’t pay more than 20% of the Medicare-approved amount, even if a doctor doesn’t accept assignment.
Emergency Foreign Travel: Some plans offer limited coverage for emergency care received while traveling outside the U.S., which could be crucial if a lung emergency occurs abroad.

Actionable Tip: Medigap plans are standardized (e.g., Plan G, Plan N) across most states, meaning Plan G from one company offers the same core benefits as Plan G from another. However, premiums can vary significantly. Purchase a Medigap policy during your Medigap Open Enrollment Period, which begins the month you turn 65 and are enrolled in Part B. During this period, you have guaranteed issue rights, meaning insurers cannot deny you coverage or charge you more due to pre-existing lung conditions. If you miss this window, you may face medical underwriting.

Specific Lung Conditions and Medicare Coverage

Medicare provides coverage for a wide range of lung conditions, from acute infections to chronic diseases and cancer.

Chronic Obstructive Pulmonary Disease (COPD)

COPD, including emphysema and chronic bronchitis, is a significant chronic lung condition affecting many Medicare beneficiaries.

Medicare Coverage for COPD (Examples):

Diagnosis & Monitoring: Part B covers doctor visits, pulmonary function tests (PFTs), chest X-rays, and CT scans used to diagnose and monitor COPD progression.
Medications: Part D covers bronchodilator inhalers (short-acting and long-acting), corticosteroid inhalers, and oral medications.
Oxygen Therapy: Part B covers oxygen equipment and supplies if medically necessary.
Pulmonary Rehabilitation: Part B covers comprehensive pulmonary rehab programs for moderate to severe COPD.
Hospitalizations: Part A covers inpatient hospital stays for COPD exacerbations.
Sleep Studies: If sleep apnea is suspected (common in COPD patients), Part B covers diagnostic sleep studies and CPAP machines.

Asthma

Asthma is a chronic inflammatory airway disease.

Medicare Coverage for Asthma (Examples):

Diagnosis & Management: Part B covers doctor visits with pulmonologists or allergists, spirometry (a type of PFT), and allergy testing if needed.
Medications: Part D covers rescue inhalers (e.g., albuterol), maintenance inhalers (e.g., fluticasone, salmeterol), and oral medications like montelukast.
Nebulizers: Part B covers nebulizer machines and Part D covers the liquid medications used with them.
Emergency Care: Part B covers outpatient emergency room visits for asthma attacks; Part A covers inpatient hospital stays if admitted.

Lung Cancer

Lung cancer diagnosis and treatment are extensively covered by Medicare.

Medicare Coverage for Lung Cancer (Examples):

Screening: Part B covers annual low-dose CT scans for eligible high-risk individuals.
Diagnosis: Part B covers diagnostic tests like chest X-rays, CT scans, PET scans, biopsies, and bronchoscopies.
Treatment:
- Surgery: Part A covers inpatient hospital costs for lung resection (lobectomy, pneumonectomy) and associated surgical services.
- Chemotherapy: Depending on administration, chemotherapy drugs may be covered under Part B (if administered in an outpatient clinic or doctor’s office) or Part D (if oral chemotherapy).
- Radiation Therapy: Part B covers outpatient radiation therapy.
- Targeted Therapy & Immunotherapy: Coverage depends on administration route; typically Part B for infused treatments and Part D for oral medications.
Rehabilitation & Palliative Care: Pulmonary rehabilitation (Part B) and hospice care (Part A) for advanced cases.

Pneumonia and Acute Respiratory Infections

Medicare provides critical coverage for acute lung infections.

Medicare Coverage for Pneumonia (Examples):

Vaccinations: Part B covers pneumococcal (pneumonia) and flu vaccines.
Doctor Visits: Part B covers visits to diagnose and treat pneumonia.
Diagnostic Tests: Part B covers chest X-rays, blood tests, and sputum cultures.
Hospitalization: Part A covers inpatient hospital stays for severe pneumonia requiring admission.
Antibiotics: Part D covers oral antibiotics; Part B covers IV antibiotics administered in an outpatient setting or hospital.

Navigating the Costs: Premiums, Deductibles, Coinsurance

Even with Medicare, you’ll have out-of-pocket costs. Understanding these helps you budget for lung care.

Premiums: Monthly payments for Part B, Part D, and potentially your Medigap or Medicare Advantage plan.
- Example: In 2025, the standard Part B premium is $185 per month. You’ll pay this regardless of your health.
Deductibles: The amount you must pay out-of-pocket before Medicare starts to pay for covered services.
- Example: The Part A deductible for each benefit period is $1,676 (2025). If you’re hospitalized for a lung infection, you pay this amount before Part A kicks in. The Part B deductible is $257 annually (2025).
Coinsurance/Copayments: Your share of the cost for covered services after you’ve met your deductible.
- Example: For most Part B services, you pay 20% of the Medicare-approved amount. So, if a pulmonologist visit is $150 (Medicare-approved), you pay $30 after your Part B deductible. Part D plans have varying copayments based on drug tiers.

Actionable Tip: Explore programs like Medicare Savings Programs (MSPs) or Extra Help (Low-Income Subsidy) if you have limited income and resources. These government programs can help pay for premiums, deductibles, and copayments, significantly reducing your out-of-pocket costs for lung care. Contact your State Health Insurance Assistance Program (SHIP) for personalized guidance.

Finding Lung Specialists Who Accept Medicare

Locating healthcare providers who accept Medicare is essential for seamless care.

Medicare.gov Physician Compare Tool: This online tool allows you to search for doctors, specialists (like pulmonologists), and other healthcare providers by specialty and location. You can filter results to show providers who accept Medicare assignment.
- Example: Go to Medicare.gov, click “Find doctors & other clinicians,” enter “pulmonology” and your zip code. Review the list for providers accepting assignment.
Direct Provider Inquiry: When scheduling an appointment, always confirm directly with the provider’s office that they accept Medicare and are “participating providers” (meaning they accept assignment).
Medicare Advantage Plan Directories: If you have an MA plan, use your plan’s online provider directory or call their customer service to find in-network pulmonologists and facilities. Staying in-network is crucial to minimize costs with these plans.
Referrals: For some Medicare Advantage plans (HMOs), you may need a referral from your primary care provider (PCP) to see a pulmonologist. Understand your plan’s referral requirements.

Actionable Tip: Even if a provider “accepts Medicare,” they might not always “accept assignment.” Always ask if they accept assignment to ensure you only pay the Medicare-approved coinsurance and deductible.

What If Medicare Denies Coverage for Lung Care?

Sometimes, Medicare may deny coverage for a service, supply, or medication related to your lung health. You have the right to appeal these decisions.

Steps to Appeal a Medicare Denial (Examples):

Understand the Denial: When Medicare or your plan denies coverage, they must send you a written notice explaining why and how to appeal. Read this “Medicare Summary Notice” (MSN) or “Explanation of Benefits” (EOB) carefully. It might state a service wasn’t medically necessary.
Level 1: Redetermination by Your Plan (for MA/Part D) or Medicare Carrier (for Original Medicare): This is the first step. You (or your doctor) submit a request for redetermination.
- Example: If your MA plan denies an extended course of pulmonary rehabilitation, you or your pulmonologist submit a written appeal, often with a letter of medical necessity explaining why the additional sessions are vital.
Level 2: Reconsideration by an Independent Review Entity (IRE): If your first appeal is denied, you can appeal to an independent review organization.
- Example: If your request for a specific, expensive inhaler is denied by your Part D plan, and the plan upholds the denial, you can appeal to the IRE, providing documentation from your doctor about why that specific medication is essential and alternatives are ineffective.
Level 3: Hearing by an Administrative Law Judge (ALJ): If the IRE denies your appeal, you can request a hearing with an ALJ if the amount in question meets a minimum dollar threshold.
Level 4 & 5: Appeals Council Review and Federal Court Review: Further appeals are possible to the Medicare Appeals Council and, ultimately, to a federal district court if the dollar amount meets the threshold.

Actionable Tip: Keep meticulous records of all medical care, bills, and correspondence with Medicare or your plan. If a denial occurs, gather supporting documentation from your doctor, such as medical records, physician letters of necessity, and clinical guidelines. You can also get free, personalized help from your State Health Insurance Assistance Program (SHIP) or the Medicare Rights Center.

Preventive Services for Lung Health Covered by Medicare

Prevention is key to maintaining lung health, especially as you age or if you have risk factors.

Preventive Services for Lung Health (Examples):

Pneumococcal Vaccines: Protect against pneumonia, a common and potentially severe lung infection. Covered 100% by Part B.
Flu Shots: Annual influenza vaccines are covered 100% by Part B to prevent seasonal flu, which can lead to severe lung complications.
COVID-19 Vaccines: Covered by Medicare.
Tobacco Cessation Counseling: If you smoke, Medicare covers counseling sessions to help you quit, which is one of the most impactful steps for lung health. Part B covers up to 8 sessions over a 12-month period.
Annual Wellness Visit: During your Annual Wellness Visit, your doctor can discuss your lung health, assess your risk factors, and recommend appropriate screenings or preventive care. This visit is covered 100% by Part B.
Lung Cancer Screening (LDCT): As mentioned, for eligible high-risk individuals, annual LDCT screening is covered.

Actionable Tip: Take advantage of these preventive services. They are often covered at no cost to you and can significantly impact your long-term lung health, preventing more serious conditions and costly treatments down the line.

Conclusion

Finding Medicare coverage for your lungs requires a clear understanding of the different parts of Medicare, how they interact, and what supplementary options are available. By actively engaging with your Medicare benefits – understanding Part A for hospital stays, Part B for medical services and DME, Part D for medications, and considering Medicare Advantage or Medigap for comprehensive coverage – you can effectively manage your lung health. Always verify coverage with your plan, ask questions, and utilize available resources like the Physician Compare tool and SHIP programs to ensure you receive the care you need without undue financial burden. Proactive management of your Medicare benefits is just as important as proactive management of your lung health.