In an effort to educate providers and beneficiaries regarding which preventive services are no cost under Medicare, the Centers for Medicare and Medicaid Services have released a power point presentation and workbook explaining these important benefits. The training and information provided in the workbook are accurate as of May 2015. Visit CMS.gov/outreach-and-education/training/cmsnationaltrainingprogram/index.html for updated versions and changes to the rules.
Universal preventive services
Most of these no or low cost preventive services are also included in most individual and family plans sold through the exchange, employer group health plans, and Medicaid or Medi-Cal health plans.
Who is eligible for preventive services?
- Medicare Preventive Services are provided to the individual if he or she has Part B. This is regardless if the Medicare beneficiary receives benefits from
- Original Medicare
- Medicare Advantage Plans
- Other Medicare health plans
Coverage for the preventive services is based on
- Medical history
- For example, men don’t necessarily qualify for a no cost preventive mammogram.
There will generally be no payment to the Medicare beneficiary if
- The doctor accepts Medicare Assignment, meaning they’ll accept Medicare reimbursement rates as payment in full.
- The doctor is in-network for the Medicare managed care plan.
- There may be charges associated with the visit or procedure if the physician performs other tests or evaluations that are not subject to the no cost preventive services.
- Section 4104 of the Affordable Care Act waives deductibles, copayments, or coinsurance for the Medicare preventive services
- Initial Preventive Physical Examination or Welcome to Medicare visit
- Yearly Wellness visit
- Grade A or B preventive services
- *Lab tests are not included in the Welcome to Medicare visit.
Healthcare services covered under Medicare at no or low cost
A few of the preventive services and their conditions for full coverage under Medicare.
Abdominal Aortic Aneurysm Screening
- May need a physician referral
- One time ultrasound screening
- No copayment or deductible with Original Medicare
Bone Mass Measurement covered in full if you meet the following criteria
- At risk for osteoporosis based on medical history
- X-rays show possible problems
- Taking prednisone or other steroid type drug
- Have hyperparathyroidism
- Monitored to asses response to FDA approved osteoporosis drug therapy
- Screenings can be every 24 months with no copayment or deductible with Original Medicare.
- Covered for all women with Medicare
- Baseline mammogram between 35 and 39 years of age
- Once a year starting at 40
- Diagnostic mammograms covered if there are signs, symptoms, or history of breast cancer.
Cardiovascular Disease Screening
- Blood test for early risk detection: heart disease, stroke
- Covered lab tests include: total cholesterol, high-density lipoproteins, triglycerides
- Screening covered once every 5 years
Cervical and Vaginal Cancer Screening
- Pap tests and pelvic exam with clinical breast exam
- Papanicolaou test (pap smear) and physician evaluation included
- Covered every 24 months or 12 months for high risk women.
Colorectal Cancer Screening
- One or more of the following tests may be covered-
- Screening Fecal Occult Blood Test
- Screening Flexible Sigmoidoscopy
- Screening Colonoscopy
- Screening Barium Enema
- Multi-target stool DNA test
- High risk individuals can have more frequent screenings with some tests.
- NOTE: If a polyp or other tissue is found and removed during a screening colonoscopy, you may have to pay 20% of the Medicare-approved amount for the doctor’s services and a copayment in a hospital outpatient setting.
- Every 12 months for high risk groups
- Family history
- African-American and 50 or older
- Hispanic and 65 or older
- 20% copayment of Medicare-approved amount.
Hepatitis B Shots (vaccine)
- Covered for people who are medium to high risk of contracting the disease
- End-Stage Renal Disease, hemophilia, and diabetes mellitus
- Individuals living with a carrier of Hepatitis B
- Homosexual men
- Illicit injectable drug users
- Staff in institutions for developmentally disabled
- Conditions that lower resistance to infection
- Certain health care professionals
- No copayment or deductible with Original Medicare
Hepatitis C Screening Test
- Covered when ordered by a primary care practitioner
- Single, once-in-a-lifetime HCB screening test if born from 1945 to 1965
- Annually, if high-risk person with prior negative HCV screening
- No copayment or deductible with Original Medicare.
Human Immunodeficiency Virus Screening
- One annual screening for individuals between 15 and 65 years
- Younger or older if at perceived risk
- Medicare beneficiaries who are pregnant, up to three voluntary screenings
- No cost for the test if provider accepts Medicare
- Pay 20% of Medicare-approved amount for visit.
Lung Cancer Screening
- Low Dose Computed Tomography once per year for
- People ages 55 to 77
- Current or former smoker who quit in last 15 years
- Must get a written order from physician
More information can be found in the training presentation and workbook.
- 2015 Medicare Preventive Services Training Presentation
- 2015-Medicare-Preventive Services Workbook
- Preventive Services Checklist