Medicare Preventive Services

Key takeaway:

• Medicare covers preventive care and refers to such visits as “Wellness Visits”.

• Medicare covers preventive care services are under Part B. Preventive services are exempt from the deductible, copays, and coinsurance. No need to worry about cost sharing.

• For a list of all that is covered by Medicare Preventive Services, see this link.

• Free Preventive Care Services are an important part of your Medicare healthcare.

What are Medicare Preventive Services?

Medicare preventive care services are a set of healthcare services and screenings that are designed to prevent or detect health issues before they become serious. Preventive service helps people stay healthy. They are offered to beneficiaries on Original Medicare.

Preventive services, also called “Wellness Visits” are provided under Medicare Part B and include dozens of preventive care services including lung cancer screening (and other cancer screening), cardiovascular care, fecal occult blood tests, immunization like Hepatitis b shots, and more.

Preventive services also include programs for health monitoring for certain risk factors and high-intensity behavioral counseling, like diabetes self-management training, medical nutrition therapy, counseling sessions, etc. Self-management training is very important since our habits make us who we are.

Does Medicare Cover Preventive Services?

Are preventive services free?

Yes, Medicare Part B covers certain preventive services and screenings. Most preventive services are available to Medicare beneficiaries at no cost.

A Medicare Advantage plan also covers many preventive services, because a Medicare Advantage plan is required to cover all of the same preventive services that are covered under Original Medicare for a Medicare approved amount. But you’ll need to use an in-network provider. Double check your costs if you’re using an out-of-network provider. The cost sharing might be different.

You should also know that the Affordable Care Act requires all private health plans to provide the full suite of preventive services with no copays or deductibles unless the plan has a grandfathered status.

What is an example of a preventive service?

Which preventive services does Medicare cover?

Annual wellness visit

Medicare covers a yearly wellness visit to create or update a personalized prevention plan based on your current health and high-risk factors.

Your first Wellness visit, performed in the first 12-month of having Medicare, is called your “Welcome to Medicare” visit. After that, preventive care can be performed once every 12 months as your “annual wellness visit.”

Cancer screening

Medicare covers screening tests for breast, cervical, colorectal cancer, lung, and prostate cancer (like a digital rectal exam).

Cancer screening, diagnostic mammograms (breast cancer screening), vaginal cancer screening, a pap test, colorectal cancer, and lung cancer screening are some of the most important preventive services for your health. If a doctor finds any early changes in your cells, it might be a life-saving screening, especially, if you have a family history of high risk for a certain type of cancer, like prostate cancer.

For example, fewer and fewer people have been diagnosed with colorectal cancer and vaginal cancer thanks to the frequent screening services. A simple pap test can reveal such potentially life-threatening viruses as HPV.

STI screening

This includes blood tests, lab tests, etc. and is especially important for high-risk categories.

AAA screening

Medicare Part B covers one screening for an abdominal aortic aneurysm screening (AAA screening) ultrasound if you’re at risk. That is, if you have a family history of abdominal aortic aneurysms, or you’re a man 65-75 and have smoked at least 100 cigarettes in your lifetime.

Cardiovascular disease screenings

Medicare covers screenings for high blood pressure, high cholesterol, and obesity, as well as cardiovascular disease.

Immunizations

Medicare covers vaccines for flu, pneumonia, hepatitis B, and others.

Diabetes screening

Medicare covers screening for people at risk for diabetes and tests to monitor and manage diabetes.

Tobacco cessation counseling

Medicare covers counseling and other interventions to help people quit smoking.

You can see even more covered preventive services and details for Medicare beneficiaries in this booklet: Your Guide to Medicare Preventive Services.

What is not a preventive service?

Services that are not considered preventive services for a Medicare beneficiary include (for example):

Treatment of an existing illness or injury

If a doctor is monitoring an existing condition or suspects you may have a new medical issue and need tests to find out, that is not preventive care. Preventive care is when we look for a medical issue before any symptoms are present.

Cosmetic procedures

Medicare does not cover cosmetic procedures, such as facelifts, etc., as these services are considered elective and not medically necessary.

Hearing aids

Medicare does not cover the cost of hearing aids or routine hearing exams, although some Medicare Advantage plans may offer limited coverage for these services.

Eye exams for eyeglasses

Medicare does not cover routine eye exams for the purpose of prescribing eyeglasses, although it does cover annual dilated eye exams for people with diabetes and certain other conditions.

While these services may not be covered as preventive services under Medicare, they may still be covered under other parts of Medicare or through other insurance policies.

“Welcome to Medicare” preventive visit

Medicare Part B covers a “Welcome to Medicare” preventive visit once within the first 12 months you have Part B.

It includes free preventive services and a review of your medical and social history related to your health, including high-risk factors.

Things to keep in mind about your first preventive service visit

When you make an appointment, tell your primary care provider you would like to schedule your “Welcome t” preventive visit. This doctor’s visit must happen in the first 12 months of getting Medicare Part B. Always remember to stay in your plan’s network.

Caution!

Original Medicare does not cover routine physicals. If you ask for a physical when scheduling the appointment, you will get a service not covered by Medicare and will need to pay for it accordingly.

Here’s what you need to bring to your first preventive service visit:

• Medical records, as well as immunization records.

• Family health history.

• A list of any prescription drugs, over-the-counter drugs, vitamins, and supplements that you’re taking, how often, and why.

How much does it cost with Original Medicare?

If your doctor or other health care provider accepts the Medicare assignment, you won’t be charged for the preventive visit, and the Part B deductible won’t apply. Make sure they accept assignment.

Preventive services recommended by the U.S. Preventive Services Task Force are covered at 100% of the Medicare-approved amount. They are free to the Medicare beneficiaries.

If additional tests or services are performed during the same visit that are not covered under Medicare’s preventive benefit, you may be required to pay coinsurance and the Part B deductible. In this case, you may be responsible for the full payment if the additional tests or services, such as a routine physical exam, are not covered by Medicare.

Yearly “Wellness” visits

Once you’ve been enrolled in Medicare Part B for over 12 months, you’re eligible to receive an annual “Wellness” visit to create or update a personalized plan for disease or disability prevention according to your current health status and various risk factors.

The yearly “Wellness” visit is not the same as routine physicals.

The preventive care visit performed within the first twelve months of Medicare is called your “Welcome to Medicare” visit. Your next yearly “Annual Wellness” visit cannot occur within 12 months of your Part B enrollment date or your first preventive visit. They must be at least twelve months apart.

But you’re not required to have had a “Welcome ” preventive visit to be eligible for a yearly “Wellness” visit.

“Wellness” tests can be taken on a schedule – once every 12 months, once every 2 years, 4 years, etc. These are not calendar years, they are 365-day years. Check your MyMedicare.gov account for when your tests can be performed.

However, once a doctor orders diagnostic services due to suspicion of a condition or disease, or for example, if your provider finds or removes other tissue during a screening colonoscopy, it is no longer “preventive care services” but considered diagnostic. It is not subject to the schedule and there will be a different type of cost sharing.

During your “Wellness” visit, you’ll need to fill out a questionnaire, called a “Health Risk Assessment”. This is to help your doctor provide a personalized prevention plan for your health. The questions are similar to your “Welcome” preventive visit.

There will also be a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. If the cognitive impairment has been observed, Medicare covers a separate visit to do a closer analysis of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a health care plan.

For an in-depth look at what else is covered by Medicare, check out my article on all that Medicare covers or peruse our blog posts for a health care subject that interests you.

At Medigap Seminars Insurance Agency we specialize in Medicare coverage and related services. Feel free to reach out to us for quotes on Medicare coverage, dental insurance, cancer protection plans and any related insurance coverage.

Sources

https://medigapseminars.org/wp-content/uploads/2021/07/Guide-To-Medicares-Preventive-Services.pdf

https://www.medicare.gov/coverage/welcome-to-medicare-preventive-visit

https://www.medicare.gov/coverage/yearly-wellness-visits

https://www.medicare.gov/coverage/preventive-screening-services