Preventive Healthcare and Medicare – What is Covered?

Numerous chronic health disorders are preventable, and Medicare covers diverse preventive healthcare services. The Affordable Care Act (ACA) mandated that specific preventive services be covered with no co-pay required, and this mandate applied to Medicare Advantage enrollees who utilize “in-network” providers as well as Original Medicare enrollees.

According to an article in Preventive Medicine in 2018, preventive colorectal screenings alone could potentially save 150,000 life-years of US residents (based on a 15 percent reduction in invasive colorectal cancer).

The following describes some of the preventive healthcare services covered by Medicare “free-of-charge”. Additionally described are some instances when you – as a Medicare beneficiary – may be charged an “out-of-pocket” co-pay for receiving preventive healthcare services.

Annual Wellness Visit versus Routine Physical Exam

Anyone enrolled in Original Medicare’s Part B for more than 12 months can receive an annual Wellness Visit from a provider that accepts Medicare insurance payments.

The purpose of this Wellness Visit is to “develop or update a personalized prevention plan, and perform a health risk assessment” (per a Medicare Learning Network [MLN] publication of the Centers for Medicare and Medicaid Services). Notably, Medicare Advantage cannot charge you a co-pay for an annual Wellness Visit as long as this is conducted by an “in-network” medical provider – and typically your Primary Care Physician (PCP).

An annual wellness visit differs from a routine physical exam in that the provider does not actually perform a “hands-on” exam of your body. Instead, some of the activities performed by the provider during a Wellness Visit under Medicare’s rules are:

• Review of the patient’s medical and family health history;
• Assessment of the risk factors for various chronic disorders and treatment options;
• Observing (and documenting) for signs of cognitive impairment;
• Obtaining height, weight, blood pressure, and other routine measurements;
• Utilization of an approved Health Risk Questionnaire to obtain patient’s written responses to questions

Breast, Colon, and Lung Cancer Screenings An annual mammogram solely for breast cancer screening purposes is covered with no co-pay required. However, a diagnostic mammogram (ordered due to the presence of a mass or other concern) typically requires a co-pay for someone enrolled in Part B of Original Medicare – and after the Part B deductible (dollar amount) has been met.

Colorectal screening is covered with no co-pay as long as no polyps are found/removed and a barium enema did not occur as part of the screening exam. Lung cancer screenings are covered with no co-pay for anyone with a smoking history.

For someone covered by Original Medicare who wants to ensure that no co-pays are charged for these aforementioned screenings, enrolling in a Medigap plan (Medicare Supplement that is a private insurance plan) with no co-pays for any type of preventive service may reduce anxiety over receiving an unexpected bill for uncovered health services.

However, Medicare Advantage-enrollees cannot enroll in a Medigap plan. Diabetes Screening Medicare enrollees who are considered at high risk of developing diabetes (Type 2) can receive up to two diabetes screenings per year. According to the National Institutes of Health (NIH), around one-third of all adults living with diabetes (Type 2) in the US are unaware that they have this disorder.

Due to the myriad possible complications of diabetes – along with the national cost-burden attributable to this chronic disorder – enabling people with diabetes to enter treatment at the earliest possible stage of their disorder is both an ACA and Medicare preventive health priority.

Heart Disease Screening Blood tests for heart disease are covered with no co-pay every five years if ordered by your Primary Care Physician (PCP). Additionally, one behavior therapy visit with your physician annually to discuss strategies for lowering your cardiovascular risk is covered with no co-pay. Nearly 27 percent of all deaths in adults aged 65 and older are due to heart attacks, so heart disease screening can enable rapid entry into treatment to potentially prevent a heart attack from occuring.

Depression Screenings

An annual screening for depression is included as one of the “no co-pay required” screenings under Medicare, and no symptoms need to be present to receive this screening. Due to the increased isolation experienced by many senior-aged people during the current Covid-19 pandemic, a depression screening may be an especially good idea.

Immunizations An annual flu shot is provided under Medicare as a preventive service with no co-pay. Likewise, a first pneumococcal (pneumonia) shot is covered under Part B of Medicare with no co-pay, if you have never received a pneumonia shot covered by Part B before (and a second pneumonia shot administered 12 months after the first shot is also covered by Medicare’s Part B with no co-pay).

If you are at medium-to-high risk for contracting Hepatitis B, immunization for this infectious disease is also covered by Medicare’s Part B with no co-pay.

The agents of UrHealth Benefits are available to assist you in understanding the preventive services offered to people enrolled in Medicare.