Understanding Medicare’s Coverage of Preventive Care Services

Preventive care helps you stay healthy so that you can avoid health issues. Medicare Part B covers a wide variety of preventive tests, screenings, vaccinations and exams at no cost to you.

The Affordable Care Act (ACA) requires most Medicare Advantage plans to cover recommended clinical preventive services without charging deductibles or copays. This includes a comprehensive yearly Wellness Visit.

Preventive care

Most health plans, including those available in the Health Insurance Marketplace, must cover a set of preventive care services—like shots and screenings—at no cost to beneficiaries. Medicare is no exception, and it provides several types of appointments for beneficiaries to get preventive services to help them stay healthy and find problems early when they are easier to treat.

For beneficiaries with Original Medicare, these appointments cost nothing if they see a doctor or other qualified health care provider who accepts assignment and is a part of the Medicare program. However, for beneficiaries with Medicare Advantage Plan coverage, a co-pay or deductible may apply. You can, however, change your Medigap plan with the CA birthday rule if need be.

The type of preventive care that Medicare offers includes health promotion, detection and diagnosis of disease, prevention of illness and injury through education and counseling, and the promotion of healthy behaviors such as regular exercise, proper nutrition and not smoking. In order for a service to be considered preventive, it must meet specific eligibility requirements and guidelines.

As long as Medicare-participating providers provide preventive care within the guidelines, they are typically reimbursed by Medicare at 100% of the Medicare-approved amount (with no cost sharing for Original Medicare beneficiaries). But many services are provided alongside health services that are diagnostic and therefore may be subject to a copay or deductible.

For example, beneficiaries are eligible for a Welcome to Medicare checkup during the first 12 months of enrollment in Medicare Part B and an annual wellness visit once they’ve had the benefit for one year. The wellness visit establishes a personalized prevention plan, reviews screening schedules and develops a checklist of recommended preventive services.

Aside from these visits, other preventive care that Medicare provides includes yearly mammograms and annual eye exams to detect cancer, diabetes, high blood pressure, cardiovascular disease and other conditions. In addition, Medicare also offers a wide range of immunizations and screenings for certain illnesses and diseases.

The Centers for Medicare and Medicaid Services, along with the US Preventive Services Task Force, developed a list of recommended tests that doctors can perform as part of preventive care to help improve beneficiary’s health. These recommendations are available on a PDF from the Medicare website.

Preventive screenings

Many Medicare beneficiaries receive preventive screenings, which are tests that help detect diseases or conditions before you have any symptoms. These tests can often be a lifesaver, especially in cases where diseases such as diabetes, cardiovascular disease and cancer are present. Preventive services and screenings can also be a valuable tool in helping you adopt healthy lifestyle habits, such as regular exercise, a balanced diet and avoidance of smoking and excessive alcohol consumption.

In addition to regular doctor visits, preventive screenings can include blood and urine tests, body mass index (BMI) calculations, and certain imaging tests. Medicare Part B typically covers an initial “Welcome to Medicare” visit and annual wellness visits, which promote prevention and offer a range of services that can help you keep up with important health care needs. During these appointments, doctors review your overall medical history, perform an in-depth head-to-toe physical exam, measure your height, weight and blood pressure, and review your potential risk for depression and falls. Medicare also offers annual screenings for diabetes and other chronic diseases, as well as shots like flu, pneumonia and hepatitis B.

Some preventive screenings are more specialized, such as the abdominal aortic aneurysm (AAA) screening ultrasound if you’re at risk for this condition due to age or family history. Medicare also covers cancer screenings for breast, cervical, colorectal and lung cancer, as well as a digital rectal exam for prostate cancer. You may need to pay a copayment, deductible or coinsurance for these screenings.

Whether or not you need to pay for the service depends on how it’s classified: Is it considered preventive or diagnostic? This is important because preventive services are typically free of charge, while diagnostic services will require you to pay the Part B deductible and/or coinsurance. For example, you’ll need to pay a deductible and/or coinsurance for a PSA test to screen for prostate cancer, but if you have a positive diagnosis for the disease, you can be eligible for up to eight sessions of counseling to help you quit smoking. Some Medicare-approved weight loss programs may also be covered, as well as various educational and support services to help you make healthy lifestyle changes.

Preventive vaccines

Vaccines work with your body’s natural defenses to help protect you from serious diseases and infections. Because of vaccines, once-common illnesses such as polio and measles have become rare or even eliminated in the United States. CDC recommends vaccination from birth through adulthood to provide you with lifelong protection against disease.

Most Medicare Advantage plans offer a variety of preventive care services that include annual wellness visits, cancer screenings and immunizations. Some plans may also provide a health savings account, gym membership and travel benefits. If you have a Medicare Advantage plan, it is important to be aware of their benefits and coverage before scheduling your annual wellness visit or requesting certain preventive services.

For Medicare beneficiaries in traditional Medicare, there are deductibles and coinsurance to consider. Part A covers inpatient hospital stays, skilled nursing facility (SNF) stays and some home health services. Part B covers physician and outpatient services, but most Part B benefits are subject to a deductible ($1,364 per benefit period in 2019) and/or coinsurance. However, there is no deductible or coinsurance for an annual wellness visit and some preventive services rated A or B by the U.S. Preventive Services Task Force and/or the Advisory Committee on Immunization Practices.

Your doctor, clinic or online account through your insurance company should have information and reminders about preventive services you’re due for. You can also check your Medicare summary card for more information about the specific benefits you’re eligible for.

More than 20 million people have Medicare Advantage plans in place, which provide all of their Medicare-covered Part A and Part B benefits through a private insurer. Many of these plans also provide supplemental benefits not covered by traditional Medicare, such as dental and vision services. In addition, most Medicare Advantage plans limit your out-of-pocket spending each year on in-network services to no more than $6,700, and typically include a yearly wellness visit. You can also purchase a Medicare Advantage plan with a supplemental rider that provides additional coverage for out-of-network services or for foreign travel. Medicare Advantage plans are not available to all beneficiaries.

Preventive dental care

Dental health is an important aspect of overall preventive care, and regular visits to your dentist and hygienist help you maintain good oral hygiene. They also help you identify and treat dental problems before they become more serious. Preventive care helps you avoid costly dental procedures and improve your quality of life. Many people don’t realize how serious poor oral health is and wait until it’s too late to get the care they need. This can lead to more complicated and expensive treatments than needed, and often results in greater financial burdens for both patients and the healthcare system.

Despite the fact that many medical conditions can have a negative impact on teeth and dental health, Medicare does not cover routine dental services. Those services that are deemed necessary by the doctor and are considered part of the treatment plan for an underlying condition, however, can be covered. This includes management of mucositis, which can be a complication of cancer chemotherapy or radiation therapy or other treatments for certain medical conditions.

For these services to be considered “medically necessary,” the patient must meet the criteria laid out by HCFA in its guidelines, including having the medical condition and need for the dental treatment. It must be provided in conjunction with the surgery, medication, or treatment that is addressing the underlying medical condition. The dental service must be performed by a dentist or other qualified provider.

The committee opted to focus only on those dental services that were determined by a medically necessary evaluation process to be cost-effective and that resulted in savings to Medicare or other payers that exceed the costs of covering these dental services. This is a different approach than previous HCFA and CBO analyses, which examined the effects of covering more than a broad category of medically necessary dental services. Nonetheless, the committee recognized that further research is needed on both the benefits of dental services for individuals with medical conditions and their impacts on the healthcare system as a whole. This will help inform clinicians in the selection of services for coverage and lawmakers in supporting access to effective prevention and screening.

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