In a recent post, we discussed the preventive services that are covered on all non-grandfathered health plans under the Affordable Care Act. Since many of you have recently started selling Medicare products—either in addition to or in lieu of individual health insurance—we thought it would also be a good idea to take a look at the preventive care available to Medicare beneficiaries.
While we’ll focus on Original Medicare (or Medicare and a supplement) in this article, keep in mind that Medicare Advantage plans are required to cover, at a minimum, the same services that Medicare does. That means you can feel comfortable talking with all of your Medicare clients about these preventive services, and that’s important because, until recently, Medicare didn’t provide much preventive care at all. Older clients who have had Medicare for a while may not realize that these preventive benefits were added.
The preventive services described below are paraphrased and in some cases copied verbatim from the Medicare.gov website. To learn more about the preventive services available to Medicare beneficiaries, take a look at the Medicare & You handbook.
A “Welcome to Medicare” preventive visit: Within the first 12 months of having Part B, Medicare beneficiaries get a one-time introductory visit that includes a review of their medical and social history related to their health and education as well as counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed. It also includes height, weight, and blood pressure measurements, a calculation of their body mass index, a simple vision test, a review of their potential risk for depression, an offer to talk with them about creating advance directives, and a written plan letting them know which screenings, shots, and other preventive services they need. This visit is covered one time and is not required for the beneficiary to be covered for yearly “Wellness” visits.
Yearly “Wellness” visits: People who have had Part B for longer than 12 months can get this visit to develop or update a personalized plan to prevent disease and disability based on their current health and risk factors. The health care provider will ask them to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit.
For both the introductory and annual visits, Medicare beneficiaries pay nothing if their doctor accepts assignment, and the Part B deductible doesn’t apply.
Abdominal aortic aneurysm screening: Medicare provides a one-time abdominal aortic aneurysm ultrasound for at-risk beneficiaries (people with a family history of abdominal aortic aneurysms or men between age 65 and 75 who have smoked at least 100 cigarettes in their lifetime). Beneficiaries must get a referral for this from their doctor.
Alcohol misuse screenings & counseling: Adults (including pregnant women) who use alcohol but don’t meet the medical criteria for alcohol dependency can get this screening. If the primary care doctor determined that the individual is misusing alcohol, he or she can get four brief face-to-face counseling sessions per year in a primary care setting.
Bone mass measurements (bone density): People at risk of osteoporosis who meet certain conditions are eligible for this test once every 24 months (or more often if medically necessary) when it’s ordered by their doctor. Some of the risk factors include estrogen deficiency, evidence of possible osteoporosis on X-rays, taking prednisone or steroid-type drugs, and hyperparathyroidism.
Cardiovascular disease screenings: To help detect conditions that may lead to a heart attack or stroke, Medicare covers screening blood tests for cholesterol, lipid, and triglyceride levels every five years when ordered by a doctor.
Cardiovascular disease (behavioral therapy): Medicare covers one visit per year with a primary care doctor to help people lower the risk of cardiovascular disease. During this visit, the doctor may discuss aspirin use (if appropriate), check the patient’s blood pressure, and give the patient tips to make sure he or she is eating well.
Cervical & vaginal cancer screening: Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancer as well as a clinical breast exam to check for breast cancer. These screening tests are covered once every 24 months for all women and once every 12 months for women at high risk for cervical or vaginal cancer or who are of childbearing age and have had an abnormal Pap test in the past 36 months.
Colorectal cancer screenings: Medicare covers several types of colorectal cancer screening tests to help find precancerous growths or find cancer early, when treatment is most effective. Depending on the type of test, the Medicare beneficiary may pay nothing or may pay coinsurance and/or a copay, as applicable.
Depression screenings: One depression screening per year is available for anyone with Part B. The screening must be conducted in a primary care setting (like a doctor’s office) that can provide follow-up treatment and/or referrals, if needed.
Diabetes screenings: Medicare covers up to two screenings each year to check for diabetes if the beneficiary has one or more risk factors such as high blood pressure (hypertension), a history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). People with two or more of the following risk factors are also eligible: age 65 or older, overweight, a family history of diabetes, a history of gestational diabetes (diabetes during pregnancy), or delivery of a baby weighing more than 9 pounds. There is no cost for these tests.
Diabetes self-management training: Medicare also covers outpatient diabetes self-management training (DSMT) to teach beneficiaries how to cope with and manage their diabetes. It includes tips for eating healthy, being active, monitoring blood sugar, taking drugs, and reducing risks. This may include one hour of individual training, nine hours of group training, and up to two hours of follow-up training each year. Beneficiaries must at least have Part B, be at risk for complications from diabetes, and receive a written order from a doctor in order to receive such training. Additional eligibility criteria may apply.
Glaucoma tests: All people with Part B who are at high risk for glaucoma are covered for a glaucoma test once every 12 months. People are at high risk if they have diabetes, a family history of glaucoma, are African American and 50 or older, or are Hispanic American and 65 or older. The beneficiary pays 20% of the Medicare-approved amount, and the Part B deductible applies. A copay will apply if received in a hospital outpatient setting.
Hepatitis C screening test: Medicare covers one Hepatitis C screening test for anyone with Part B and yearly repeat screening for certain people at high risk. People born between 1945 and 1965, people with a current or past history of illicit injection drug use, or people who received a blood transfusion before 1992 are at a higher risk for Hepatitis C. There is no cost for the screening test if the doctor or other qualified health care provider accepts assignment.
HIV screening: Medicare covers HIV (Human Immunodeficiency Virus) screenings once every 12 months for people who are younger than 15 or older than 65 who are at increased risk for the virus, people between 15 and 65 who ask for the test, and people who are pregnant. There is no cost for the test if the doctor or other health care provider accepts assignment.
Lung cancer screening: Medicare covers a lung cancer screening with Low Dose Computed Tomography (LDCT) once per year for people age 55-77 who are asymptomatic (they don’t have signs or symptoms of lung cancer), are either a current smoker or have quit smoking within the last 15 years, have a tobacco smoking history of at least 30 “pack years” (an average of one pack a day for 30 years), and get a written order from their physician.
Mammograms (screening): Medicare covers a screening mammogram once every 12 months as well as a diagnostic mammogram when medically necessary to women with Part B who are 40 or older. Women between 35-39 can get one baseline mammogram. There is no cost for the screening test if the doctor or other qualified health care provider accepts assignment. For the diagnostic mammogram, the beneficiary pays 20% of the Medicare-approved amount after meeting the annual Part B deductible.
Nutrition therapy services: Medicare covers medical nutrition therapy (MNT) services and certain related services which may include an initial nutrition and lifestyle assessment, one-on-one nutritional counseling, and follow-up visits to check the patient’s progress in managing his or her diet. People with Part B who have diabetes, have kidney disease, or who have had a kidney transplant in the last 36 months are eligible with a referral from their doctor and pay nothing if the doctor or other health care professional accepts assignment.
Obesity screenings & counseling: Medicare covers behavioral counseling sessions to help people lose weight when it is provided in a primary care setting (like a doctor’s office) where it can be coordinated with the patient’s other care and a personalized prevention plan. Part B beneficiaries with a body mass index (BMI) of 30 or more are eligible and pay nothing for this service if the primary care doctor accepts assignment.
Prostate cancer screenings: Medicare covers a digital rectal exam as well as a prostate specific antigen (PSA) test once every 12 months for all men over 50 who have Part B. The beneficiary pays 20% of the Medicare-approved amount for a digital rectal exam after meeting the Part B deductible if the screening is performed in a doctor’s office and a copayment if it’s performed in a hospital outpatient setting. There is no cost for the PSA test but there may be an additional cost for the doctor’s services if the provider does not accept assignment.
Sexually transmitted infections screening & counseling: Medicare Part B covers sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis and/or Hepatitis B once every 12 months or at certain times during pregnancy. If referred by a primary care physician, Medicare also covers up to two individual, face-to-face, high-intensity behavioral counseling sessions (20-30 minutes) each year for sexually active adolescents and adults at increased risk for STIs. There is no cost for STI screenings or counseling if the primary care doctor or practitioner accepts assignment.
Flu shots: People with Part B can get one flu shot per flu season at no cost if the doctor accepts assignment.
Hepatitis B shots: Medicare covers Hepatitis B shots for beneficiaries who are at high or medium risk for Hepatitis B. The risk for Hepatitis B increases for people who have hemophilia, End-Stage Renal Disease (ESRD), diabetes, or certain conditions that lower their resistance to infection. There is no cost for the shot if the doctor or other qualified health care provider accepts assignment.
Pneumococcal shots: Medicare covers a pneumococcal shot to prevent pneumococcal infections (like certain types of pneumonia) and a different second shot one year later if necessary. All people with Part B are covered and pay nothing if the doctor accepts assignment.
Tobacco use cessation counseling: Medicare covers up to eight (8) face-to-face visits in a 12-month period for all people with Part B who use tobacco. There is no cost if the health care provider accepts assignment.
This has been a long post, and there’s good reason for that: because Medicare covers a lot of preventive care. If you sell Medicare-related products like Medicare Advantage plans or Medicare supplements, chances are that the only time your clients learn about their benefits is when you visit with them, so it’s a great time to review the various types of preventive care that they may be eligible for. We all know that it’s far better to catch conditions early when the treatment is less costly and more effective, and our clients are much more likely to use these valuable benefits if they know what they have.
We’ll conclude by pointing you toward a short video Medicare has put together about the preventive services available to Medicare beneficiaries. You may want to consider putting this on your website.