Does Medicare pay for Preventative Services and Procedures?

Medicare Preventative Services and ProceduresDoes Medicare pay for preventative services and procedures? Whether you are new to Medicare or have been enrolled for some time, this is one of the most common questions recipients ask. And the answer…more and more, is “Yes”.

Since 2011, in accordance with changes mandated by the Affordable Care Act (ACA), beneficiaries have gained increased access to many important preventative services and screenings.  However, the amount you pay for these services varies depending on whether you have Original Medicare or a Medicare Advantage Plan (like an HMO or PPO).

Health reform policy makers are focusing on early detection of disease as the optimal way to maintain good health and reduce overall health care costs on a national level. Though these new policies have reduced barriers to more preventative care/screening procedures, the changes will only become viable if beneficiaries are informed and take advantage of what is now covered.

Use the checklist below to determine what preventative care and screening services are covered by a plan. You can also go to Medicare.gov for a list of preventative services and screenings covered by Original Medicare.

YEARLY WELLNESS VISITS

The most basic preventative care is the annual ‘Physical’ or ‘Wellness Visit’. Medicare currently pays for two types of these visits. Either your “Welcome to Medicare” exam, scheduled during your first twelve months of enrollment, or a yearly ‘Wellness Visit’ accompanied by a personalized prevention plan for all beneficiaries.

CARDIOVASCULAR SCREENINGS

Heart disease is still the leading cause of death in the United States for both men and women. Medicare covers 1 visit per year to help lower your risk for cardiovascular disease. Your doctor will check your blood pressure, discuss heart healthy lifestyle changes and identify your risk factors. If appropriate, daily aspirin use may be recommended. A blood test for heart disease is also periodically covered. Studies prove lowering your cholesterol and blood pressure significantly reduce your risk of heart attack and stroke.

DIABETES SCREENING

Are you over 65? Overweight? Have a family history of diabetes? Have a history of gestational diabetes (diabetes during pregnancy), or delivered a baby weighing more than 9 lbs? If you answered yes to two or more of these questions, Medicare may pay for up to 2 Fasting Blood Glucose tests per year. Other risk factors such as high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity, or history of high blood sugar also qualify you to receive this benefit at little or no cost.

COLON CANCER SCREENING

If detected early, colorectal cancers rank among the most treatable, even curable diseases. Detection MUST take place before the disease has been allowed to spread outside the colon wall. Medicare covers several types of colorectal cancer screening tests to help find precancerous growths or find cancer early, when treatment is most effective.  All people are eligible for a screening colonoscopy generally once every 10 years, once every 2 years if you’re at high risk. Beneficiaries over age 50 are eligible for a fecal occult blood tests once a year, and a flexible sigmoidoscopy generally once every 4 years. Your physician can help identify your risk factors.

MAMMOGRAM (BREAST CANCER SCREENING)

All women with Medicare ages 40 and older can get a breast cancer screening mammogram every 12 months. (Medicare also pays for one baseline mammogram for women with Medicare between ages 35 and 39)

PROSTATE CANCER SCREENINGS (PSA)

Early detection of Prostate cancer is also covered by Medicare. Coverage for these screening tests begins for men the day after their 50th birthday, once every 12 months thereafter. A blood test called the PSA (Prostate Specific Antigen) is covered at no cost. The digital rectal exam generally is subject to a deductible and 20% of Medicare approved amount.

Below is a complete list of preventative procedures for which Medicare covers the cost. Some are only covered when certain prerequisite risk factors are present, or if you have been given a referral from your primary care physician. A few may be subject to cost sharing. Consult your “Medicare and You” hand book or Medicare.gov for specific guidelines.

  • “Welcome to Medicare” Preventative Visit (one-time) or Yearly “Wellness Visit”
  • Abdominal Aortic Aneurysm Screenings
  • Alcohol misuse screenings & counseling
  • Bone Mass Measurements
  • Breast Cancer Screening (Mammogram)
  • Cardiovascular Screenings
  • Cervical and Vaginal Cancer Screening
  • Colorectal Cancer Screening:
    • Fecal Occult Blood Test
    • Flexible Sigmoidoscopy
    • Colonoscopy
    • Barium Enema
  • Depression screenings
  • Diabetes Screenings
  • Diabetes Self-Management Training
  • Glaucoma Tests
  • Hepatitis C Screening Tests
  • 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 (counseling for people with no sign of tobacco-related disease)
  • Yearly “Wellness” visit

Understanding Medicare plans and their coverage can be confusing. To discuss any questions or concerns you may have regarding your current Medicare insurance needs, the knowledgeable, licensed sales agents at HealthPlanOne’s Medicare Solutions agency are well equipped to assist you.               Call us at 1-800-328-7305.