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Medicare Coverage of Preventive Services and Screenings

 

Medicare pays for many preventive services to keep beneficiaries healthy. Preventive services can find health problems early, when treatment works best, and can keep them from getting certain diseases. These services include exams, shots, lab tests, screenings, as well as, programs for health monitoring, and counseling and education to help them take care of their own health.

While some of the following Medicare preventive services and screenings will be covered at no cost to you, many do require you to pay your Part B deductible, copay, and coinsurance. And even some preventive services that are $0, will require you to pay out of pocket costs if the test requires a biopsy, diagnostic testing, or additional testing. 

List of Medicare Preventive Services and Screenings

Medicare Part B will cover all or part of the following services and screenings (remember you may owe your Part B deductible, copays, and 20% coinsurance):

  • Abdominal aortic aneurysm screening
  • Alcohol misuse screenings & counseling
  • Bone mass measurements (bone density)
  • Cardiovascular disease screenings
  • Cardiovascular disease (behavioral therapy)
  • Cervical & vaginal cancer screening
  • Colorectal cancer screenings
  • Depression screenings
  • Diabetes screenings
  • Diabetes self-management training 
  • Glaucoma tests
  • Hepatitis C screening test
  • HIV screening
  • Lung cancer screening
  • Mammograms (screening) 
  • Nutrition therapy services
  • Obesity screenings & counseling
  • One-time “Welcome to Medicare” preventive visit
  • Prostate cancer screenings 
  • Sexually transmitted infections screening & counseling
  • Shots: Flu shots, Hepatitis B shots, Pneumococcal shots
  • Tobacco use cessation counseling
  • Yearly “Wellness” visit

Medigap plans can cover preventive services and screenings. While some of the preventive care above requires that you pay your Part B deductible, copays, and coinsurance - this is where Medigap kicks in. A Medigap or Medicare Supplement plan can pay all or part of these costs by covering your Part B deductible, copays, and coinsurance.

Vaccinations

Coverage is provided for the following vaccinations. These vaccinations are covered only under Part B regardless of the setting in which they are administered, even during inpatient hospital stays.

Hepatitis B Vaccination

Payment for the hepatitis B vaccine and its administration is only available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B. 

High risk individuals include:

  • Persons with end stage renal disease
  • Persons with hemophilia who received Factor VIII or IX concentrates
  • Clients of institutions for the mentally handicapped
  • Homosexual men
  • Persons who live with a person who is a hepatitis B virus carrier
  • Illicit drug users.

Individuals at intermediate risk include:

  • Staff in institutions for the mentally handicapped 
  • Workers in health care professions who have frequent contact with blood or blood-derived body fluids during their work

Medicare beneficiaries that are currently positive for antibodies for hepatitis B are not eligible for this benefit. Medicare reimburses at 100 percent of the Medicare allowed amount. The deductible and coinsurance are waived.

Influenza Virus Vaccination

Medicare does not require the vaccine be ordered by a doctor of medicine or osteopathy; therefore, a beneficiary may receive the vaccine upon request without a physician's order and without physician supervision. However, the provider of flu shots must have a Medicare provider identification number in order to bill Medicare for payment. Medicare will generally pay for only one flu shot per beneficiary each flu season.

Medicare Part B reimburses for the influenza vaccine and its administration at 100 percent of the Medicare allowance. The Medicare Part B deductible and coinsurance do not apply for beneficiaries with standard fee-for-service Part B coverage.

Pneumococcal Pneumonia Vaccination (PPV)

PPV does not need to be ordered by a physician. Medicare allows an initial pneumococcal vaccine to Medicare beneficiaries who never received the vaccine under Medicare Part B; and a different, second pneumococcal vaccine 1 year after the first vaccine was administered.

Payment for the vaccine and its administration will be made at 100 percent of Medicare’s allowed amount. The Medicare Part B deductible and coinsurance do not apply for beneficiaries with standard fee-for-service Part B coverage. 

Screenings/Therapies/Behavioral Services

Colorectal Cancer Screening

Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. This coverage is subject to certain coverage, frequency, and payment limitations. Medicare will waive the coinsurance and annual Medicare Part B deductible for colorectal cancer screening tests.

Annual deductible is waived for surgical procedures furnished on the same date and same encounter as Colonoscopy, Flexible Sigmoidoscopy, or Barium Enema that were initiated as colorectal cancer screening services. 

In 2015, the definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies. As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.

Effective for claims with dates of service on or after January 1, 2015, append modifier -33 to the anesthesia CPT code 00810 when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (G0105 and G0121) to waive beneficiary copayment/coinsurance and deductible.

Prostate Cancer Screening

Medicare will cover prostate cancer screening test(s)/procedure(s) annually for the early detection of prostate cancer subject to certain coverage, frequency, and payment limitations.

Diabetes Screening Tests

Diabetes screening laboratory tests are covered for persons at risk for developing diabetes subject to certain coverage, frequency, and payment limitations. There is no deductible or coinsurance (waived).

Beneficiaries diagnosed with pre-diabetes - Medicare provides coverage for a maximum of two diabetes-screening tests per calendar year (but not less than 6 months apart).

Beneficiaries previously tested, but not diagnosed with pre-diabetes or never tested - Medicare provides coverage for one diabetes screening test per year (i.e., at least 11 months have passed following the month in which the last Medicare-covered diabetes screening test was performed).

Medicare Diabetes Prevention Program (MDPP) Expanded Model

For information on MDDP please visit the Centers for Medicare & Medicaid Services website.

Cardiovascular Screening Tests

Cardiovascular screening tests are covered for all Medicare beneficiaries. Coverage includes tests for total cholesterol, high-density lipoprotein and triglycerides once every 5 years. There is no deductible or coinsurance.

Glaucoma Screening

Medicare provides coverage of annual glaucoma screening for individuals at high risk for glaucoma including African Americans age 50 or older, individuals with a family history of glaucoma, Hispanic Americans age 65 or over and individuals with diabetes. Deductible and coinsurance apply.

Bone Mass Measurements

Coverage is provided for bone mass measurement procedures for certain Medicare beneficiaries who fall into at least one of the categories listed below. It is covered every 2 years; more frequently if medically necessary. There is no deductible or coinsurance.

  • Women determined by their physician or qualified NPP (non-physician practitioner) to be estrogen deficient and at clinical risk for osteoporosis;
  • Individuals with vertebral abnormalities
  • Individuals getting (or expecting to get) glucocorticoid therapy for more than 3 months; 
  • Individuals with primary hyperparathyroidism; or
  • Individuals being monitored to assess response to U.S. Food & Drug Administration (FDA)-approved osteoporosis drug therapy

Screening Pap Tests

Screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under state law to perform the examination). It is covered annually if at high risk for developing cervical or vaginal cancer or childbearing age with an abnormal Pap test within the past 3 years; or every 2 years for women at normal risk. There is no deductible or coinsurance.

Screening Pelvic Examination

Medicare Part B pays for a screening pelvic examination if it is performed by a doctor of medicine or osteopathy, or by a certified nurse midwife, a physician assistant, nurse practitioner, or clinical nurse specialist who is authorized under State law to perform the examination. It is covered annually if at high risk for developing cervical or vaginal cancer, or childbearing age with an abnormal Pap test within the past 3 years; or every 2 years for women at normal risk This examination does not have to be ordered by a physician or other authorized practitioner. There is no deductible or coinsurance.

Screening Mammography

Medicare Part B provides coverage for a screening mammography when performed by a certified provider. A screening mammography is a routine radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician's interpretation of the results for the procedure. Medicare covers one baseline for women aged 35-39 and annually for women aged 40 and older. There is no deductible or coinsurance.

Effective January 1, 2015, HCPCS code 77063 (Screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure)), must be billed in conjunction with the screening mammography HCPCS code G0202 (Screening mammography, producing direct digital image, bilateral, all views, 2D imaging only).

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

Medicare will pay for a one-time ultrasound screening for AAA for beneficiaries who meet certain conditions. The beneficiary need only obtain a referral from their physician, physician assistant, nurse practitioner, or clinical nurse specialist. There is no deductible or coinsurance.

Human Immunodeficiency Virus (HIV) Screening

Medicare covers HIV screening annually for Medicare beneficiaries between the ages of 15 and 65 without regard to perceived risk; or for Medicare beneficiaries younger than 15 and adults older than 65 who are at increased risk for HIV infection. There is no deductible or coinsurance.

For beneficiaries who are pregnant, this coverage is available 3 times per pregnancy:

  • First, when a woman is diagnosed with pregnancy;
  • Second, during the third trimester; and
  • Third, at labor, if ordered by the woman’s clinician

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease

Medicare covers IBT annually for all beneficiaries:

  • Who are competent and alert at the time counseling is provided; and
  • Whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting meet certain demographics and whose services are furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. 

There is no deductible or coinsurance.

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

All Medicare beneficiaries are eligible for alcohol screening.

Medicare beneficiaries who screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence) are eligible for counseling if: 

  • They are competent and alert at the time counseling is provided; and
  • Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

There is no deductible or coinsurance.

Screening for Depression

All Medicare beneficiaries are eligible for an annual screening. The services must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. There is no deductible or coinsurance.

Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

Medicare provides payment subject to certain coverage, frequency, and payment limitation for sexually active adolescents and adults at increased risk for STIs. There is no deductible or coinsurance.

Frequency

One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant

  • One annual occurrence of screening for syphilis in men at increased risk
  • Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening
  • One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs
  • One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence at delivery if at continued increased risk for STIs

Intensive Behavioral Therapy (IBT) for Obesity

For coverage requirements of intensive behavioral therapy for obesity, there is no deductible or coinsurance.

IBT is covered at the following frequency:

  • First month: one visit every week;
  • Months 2 – 6: one visit every other week;
  • At the 6-month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed.
  • Months 7 – 12: one visit every month if certain requirements are met
  • To be eligible for additional face-to-face visits occurring once a month for an additional 6 months, beneficiaries must have lost at least 3 kg. 
  • For beneficiaries who do not achieve a weight loss of at least 3 kg during the first 6 months, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

Initial Preventive Physical Exam (IPPE)

Coverage for IPPE, also known as the Welcome to Medicare Physical Exam, is a once in a lifetime benefit and must be furnished no later than 12 months after the effective date of the first Medicare Part B coverage. (Note: The screening EKG is an optional IPPE service).

Advanced Care Planning (ACP)

ACP is a separate Part B service that enables Medicare patients to make important decisions over the type of care they receive and when they receive it.

ACP services may be billed by physicians and non-physician practitioners (NPPs); they may also be billed by hospitals. 

  • There are no place-of-service limitations on the new ACP codes. ACP services can be appropriately furnished in both facility and non-facility settings, and are not limited to particular physician specialties.
  • ACP can be an optional element of Initial or Subsequent Annual Wellness Visit (AWV) upon agreement with the patient
  • Face-to-face by physician or other qualified health care professional with patient, family members(s) and/or surrogate
  • Voluntary ACP means the face-to-face service between a physician (or other qualified health care professional) and the patient discussing advance directives, with or without completing relevant legal forms. 

Annual Wellness Visit (AWV)

Coverage extends to all Medicare beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not received an IPPE or AWV within the past 12 months. There is no deductible or coinsurance.

Smoking and Tobacco-Use Cessation Counseling Services

Medicare covers intermediate and intensive cessation counseling subject to eligibility and frequency restrictions. Medicare reimburses at 100% of the Medicare allowed amount. There is no deductible and coinsurance.

  • Hospitals / other providers subject to the Outpatient Prospective Payment System (OPPS)
  • Frequency: Two cessation attempts per year; each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions per year.

Diabetes Self-Management Training (DSMT)

DSMT is covered for certain Medicare beneficiaries who:

  • Are diagnosed with diabetes and
  • Who receive an order for DSMT from the physician or qualified NPP treating the beneficiary’s diabetes

Frequency

  • Initial year: Up to 10 hours of initial training within a continuous 12-month period
  • Subsequent years: Up to 2 hours of follow-up training each year after the initial year

Deductible and coinsurance apply.

Medical Nutrition Therapy (MNT)

MNT is covered for certain Medicare beneficiaries:

  • Who receive a referral from their treating physician; and
  • Are diagnosed with diabetes, renal disease, or who have received a kidney transplant within the last 3 years; and
  • A registered dietitian or nutrition professional must provide the services

Frequency

  • First year: 3 hours of one-on-one counseling; or 
  • Subsequent years: 2 hours

There is no deductible and coinsurance.

Hepatitis C Virus (HCV)

Effective June 2, 2014, Medicare began covering HCV screening when ordered by the beneficiary’s primary care physician or practitioner and performed by an eligible Medicare for beneficiaries who meet either of the following conditions:

  • Adults at high risk for HCV infection
  • “High risk” - persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992
  • Repeat screening for high risk persons is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test.
  • Adults who do not meet the high-risk definition, but who were born from 1945 through 1965, A single, once-in-a-lifetime screening test is covered

There is not coinsurance and deductible.

Lung Cancer Screening

Effective February 5, 2015, Medicare covers lung cancer screening counseling and a shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with Low Dose Computed Tomography (LDCT). 

This screening is covered annually for Medicare beneficiaries who meet the criteria listed in the CMS

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