Medicare & Preventive Services
Medicare Part B coverage offers a wide variety of preventative healthcare and other screenings to its enrollees, including the “Welcome to Medicare” visit and an Annual Wellness Visit (AWV). These services are intended to prevent diseases altogether as well as detecting and treating diseases early. As established by the Affordable Care Act, many of these are provided at no charge to you.
Within the first year of enrolling in Medicare Part B, you are entitled to a free “Welcome to Medicare” visit in which your doctor will discuss your medical history with you and evaluate you for possible risk of disease. This visit will usually include the following:
- A review of your medical and family history, current health conditions, and prescriptions you take.
- Checking your blood pressure, vision, weight, and height to get a baseline for your care.
- Recommendations for preventive screenings and services, such as cancer screenings and shots.
If you changed physicians when enrolling in Medicare, you should bring your medical records and a list of any prescription drugs you are currently taking to this appointment so that you and your new doctor can develop a plan for your healthcare. After your initial visit, Medicare will cover an AWV once per year, which will entail many of the same services. The AWV is also used to develop a personalized plan to help prevent disease or disability based on your current health status and any risk factors.
Both of these appointments are completely covered by Medicare Part B and you will not be charged for the initial visits. If your physician orders or performs additional tests and services during these visits, you will be financially responsible for associated fees if the tests are not covered or only partially covered by Medicare.
In addition to a yearly well patient appointment, Medicare offers many types of screening and services designed to detect or prevent illness. Some of these are offered at little or no cost to you, depending on certain eligibilities or time frames. For example, the bone mass measurement (bone density test) is usually free only once every 24 months to patients at risk of osteoporosis. However, it may be covered more often if your doctor determines it is medically necessary or if your medical history reveals other qualifying factors.
Preventive Services and Screenings Covered by Medicare
- Abdominal Aortic Aneurysm Screening
- Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care
- Annual Wellness Visit (Including Personalized Prevention Plan Services)
- Bone Mass Measurements
- Cancer Screenings
- Breast Cancer (mammograms and clinical breast exam)
- Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])
- Colorectal Cancer
- Fecal Occult Blood Test
- Flexible Sigmoidoscopy
- Barium Enema
- Prostate (PSA blood test and Digital Rectal Exam)
- Cardiovascular Disease Screening
- Depression Screening in Adults
- Diabetes Screening
- Diabetes Self-Management Training
- Glaucoma Screening
- Human Immunodeficiency Virus (HIV) Screening
- Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
- Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)
- Intensive Behavioral Therapy for Cardiovascular Disease
- Intensive Behavioral Therapy for Obesity
- Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
- Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs
- Tobacco-Use Cessation Counseling
Preventive Services & Medicare Out-of-Pocket Costs
Recently there has been discussion concerning patients being charged for services they thought were preventive and covered by their plans. Adding to the confusion, there are a number of preventive services stipulated by the Affordable Care Act which insurers are not quite certain what they are supposed to cover. To help mitigate this confusion, legislation is currently being worked on to clarify regulations. For example, under the current law Medicare beneficiaries can get free colorectal cancer screenings but if a polyp is discovered and removed during the screening the patient is billed as if the procedure was for treatment instead of prevention. However, in May 2014 a bill was introduced to Congress to make all colorectal cancer screenings cost-free including visits where a polyp is removed.
To avoid unnecessary or unexpected out-of-pocket costs for preventive services it is important remember follow-up tests after abnormal findings, evaluation and monitoring of ongoing medical issues; diagnosing and investigating new symptoms, and most medications do not qualify as preventive services. You should always ask your doctor if you are not sure if a service qualifies as preventive care before services are rendered. Furthermore, seeing a provider outside of your plan’s network for preventive care may not be covered by your plan. One option to avoid or reduce unnecessary out-of-pocket costs is to schedule an appointment solely for your annual wellness visit and a follow-up appointment to address any significant health problems that arise from the AWV.
Insurers are working on educating their beneficiaries on exactly which preventive services are covered and many are including more information on preventive services on their websites. Additionally, HHS funded the development of a free phone application called “myfamily” which focuses on preventive benefits covered by the Affordable Care Act. The app helps educates consumers on which services they are are entitled to without having to pay a co-payment, helps consumers track their appointments, medical records and vaccinations, and provides health tips and information tailored to each member of a family.