In recent years, most health insurance companies began covering a variety of preventive screenings and services, often at no cost to the beneficiary. The reason is simple: Preventive healthcare is much cheaper than treatment. Medicare and other insurers joined with healthcare providers to encourage patients to take a more active role in their personal health. The goal was twofold: reducing healthcare costs and improving overall health and wellness. In this post, we describe the preventive screenings covered by Medicare and why you should take advantage of this benefit.
Welcome to Medicare and Yearly Wellness Visits
Medicare covers a wellness visit every 12 months. Assuming your provider accepts assignment, your cost for this service is zero.
During your first 12 months with Medicare Part B, your yearly exam is called the Welcome to Medicare visit. This preventive service is a great way to get a good baseline reading of your overall health. It includes measurement of vitals such as height, weight, and blood pressure, but also a review of your medical history and education about Medicare and other preventive services. In addition, your exam includes:
- A basic vision test
- A body mass index calculation
- Flu and pneumococcal shots as needed
- Cognitive assessment
- A depression assessment
- A discussion about advance directives
In addition, your doctor provides a written plan that details the screenings and other preventive services recommended for the coming year.
The yearly wellness exam is essentially the same. You get one wellness visit every 12 months.
Medicare Part B covers a variety of cancer screenings that have been proven to help diagnose cancer early. These include:
Cervical and vaginal cancer screenings
Part B covers Pap tests and pelvic exams. In addition, the pelvic exam includes a clinical breast exam (i.e. a physical performed by your provider, not a mammogram). Screenings are covered every 24 months unless you’re considered high risk or have had an abnormal Pap test within the past three years. Those aged 30 to 65 also qualify for the human papillomavirus (HPV) test every five years.
Colorectal cancer screenings
Part B covers a variety of tests intended to diagnose colorectal cancer, including:
- Multi-target stool DNA tests every three years
- Screening fecal occult blood tests every 12 months
- Screening colonoscopies every 24 months (high risk patients), every 120 months (normal risk), or 48 months after a flexible sigmoidoscopy
- Screening barium enemas every 48 months (aged 50 or older) or every 24 months (high risk)
- Screening flexible sigmoidoscopies every 48 months (most people aged 50 or older) and 120 months after a screening colonoscopy
Lung cancer screenings
Screenings with low dose computer tomography (LDCT) are covered yearly for beneficiaries who meet all of the following requirements:
- Age 55 to 77
- Have no lung cancer symptoms
- Either smoke currently or quit within the past 15 years
- Have a smoking history of 30 or more pack years (averaged one pack/day for 30 years)
- Your doctor ordered the screening in writing
Part B covers one baseline mammogram for women aged 35 to 39 as well as screening mammograms yearly for women over the age of 40. If deemed medically necessary, diagnostic mammograms are covered more frequently. However, you pay 20 percent of the Medicare-approved amount and the Part B yearly deductible applies.
Prostate cancer screenings
Men over the age of 50 qualify for yearly prostate cancer screenings:
- The digital rectal exam costs you 20 percent of the Medicare-approved amount plus the Part B deductible if received in your doctor’s office. If you get the screening in a hospital outpatient setting, you have a co-payment.
- There is no fee to you for the prostate specific antigen (PSA) blood test.
Screenings for Chronic Conditions
The earlier you discover chronic conditions, the easier they are to treat. In addition, treatment is typically more successful, too.
If you’re eligible, Medicare Part B covers a wide array of screenings to detect chronic conditions.
- Abdominal aortic aneurysm screening: If you are a male aged 65 to 75 who has smoked at least 100 cigarettes during your lifetime, you qualify for this screening. Aortic aneurysms are most common in patients with cardiovascular disease.
- Bone mass measurements: Most commonly prescribed when your doctor suspects you either have or are at increased risk of osteoporosis.
- Cardiovascular disease screenings: All Part B beneficiaries qualify for blood tests to determine cholesterol, lipid, and triglyceride levels every five years. If your doctor orders these, he or she is looking for a condition that raises your risk of heart attack or stroke.
- Depression screenings: Covered yearly, this screening is part of your yearly wellness visit. It must take place in a primary care setting.
- Diabetes screenings: Part B covers up to two screenings per year if you are diagnosed with pre-diabetes or your doctor feels you’re at risk for diabetes. Qualifying risk factors include high blood pressure, a history of abnormal cholesterol or triglyceride levels, historically high blood sugar, and obesity. In addition, family history and a personal history of gestational diabetes qualifies, as does delivering a baby that weighs 9 pounds or more.
- Glaucoma tests: You’re eligible for yearly glaucoma testing if you match at least one of the following: have diabetes, a family history of glaucoma, are an African American aged 50 or older, or are Hispanic aged 65 or older.
- Hepatitis B virus infection screenings: If you’re considered high risk or are pregnant, you’re covered for a yearly screening assuming you don’t get a Hepatitis B shot.
- Hepatitis C screenings: Medicare covers a single screening if you had a blood transfusion before 1992, were born between the years 1945 and 1965, or at elevated risk for Hepatitis C due to intravenous drug use.
- HIV screenings: You’re eligible for yearly HIV tests if you are aged 15 to 65 or considered high risk for HIV. Pregnant women are covered for three screenings throughout their pregnancy.
Preventive Shots Covered by Medicare Part B
In addition to preventive screenings, Part B covers certain immunizations. These include:
- Flu shots: You get one flu shot per flu season under Medicare Part B.
- Hepatitis B shots: You qualify for Hepatitis B shots if you’re either medium or high risk for the disease. To qualify, one of the following must be true for you: You have diabetes, hemophilia, or End-Stage Renal Disease (ESRD). You also qualify if you live with someone who has Hepatitis B or are a healthcare worker in frequent contact with bodily fluids.
- Pneumococcal shots: You qualify for two pneumococcal shots assuming the second one is administered at least 12 months after the first.
Lifestyle Screenings and Counseling
Finally, Medicare Part B covers an array of services designed to help you make lifestyle changes to improve overall health and wellness.
- Alcohol misuse screenings and counseling: Covered yearly for adults who use alcohol but don’t qualify as alcohol-dependent.
- Cardiovascular behavioral therapy: Covered yearly, this visit typically includes a blood pressure check and general advice from your doctor regarding aspirin therapy and tips on diet.
- Diabetes self-management training: If you have diabetes and a written order from your doctor, you may qualify for 10 sessions during a calendar year.
- Nutrition therapy services: You may qualify if you have diabetes, kidney disease, or had a kidney transplant within the past three years.
- Obesity screenings and counseling: If you have a body mass index of 30 or higher, you may qualify for a dietary assessment and counseling.
- Smoking and tobacco use cessation counseling: Part B covers eight sessions in a 12-month period
- Sexually transmitted infections (STI) screenings and counseling: Includes screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B if you are pregnant or considered high risk for an STI
As always, if you have any questions about your Medicare coverage, call us toll-free at 855-350-8101 to speak to a licensed agent.
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