How Medicare Covers Preventive Services

Medicare covers many preventive services. Whether you have Original Medicare (Parts A and B) or a Medicare Advantage Plan (Private Medicare Health Plan).

Expanded Preventive Services under the Affordable Care Act

The Affordable Care Act (ACA) has improved coverage for seniors by expanding the number of no-charge Medicare preventive and wellness services—that is, visits with no applicable Part B deductible or coinsurance. For many seniors this means no longer having to delay check-ups and preventive care like cancer screenings, flu shots, and vaccines.

The ACA is also helping to close the Part D prescription drug “donut hole,” a coverage gap that, when reached, means seniors must pay out of pocket for prescription drugs. Year by year the ACA is narrowing this coverage gap, until 2020 when it will disappear. Once the coverage gap is closed, seniors will pay only their normal drug copayments.

Medicare-Covered Preventive Services

Those with Original Medicare (Parts A and B) will have no coinsurance or deductible for certain preventive services recommended by the U.S. Preventive Services Task Force, as long as the doctor accepts Medicare assignment. Accepting Medicare assignment means the doctor agrees to be paid directly by Medicare and accept the amount that Medicare pays, and that he/she agrees not to bill patients for more than the Medicare deductible or coinsurance amount.

Here’s a sampling of some of the no-charge Medicare preventive services:

  • Abdominal aortic aneurysm screening—there is no charge for this test as long as the doctor accepts Medicare assignment.
  • Bone density measurement—there is no charge for this test as long as the doctor accepts Medicare assignment.
  • Diabetes screening—Medicare will cover certain tests at no charge for those with specific risk factors for diabetes, such as high blood pressure and obesity.
  • Screening mammograms—Medicare will cover a screening mammogram at no charge, as long as the doctor takes Medicare assignment.
  • Wellness visits—there is no charge for the “Welcome to Medicare” preventive visit or the yearly “wellness” visit if the doctor accepts Medicare assignment. Note that if your doctor performs additional tests or services during the same visit that aren’t part of the no-charge preventive benefits, you will have to pay any applicable coinsurance and deductible.

Diagnostic vs. Screening Tests

It’s important to note that the distinction between screening tests and diagnostic tests. Many preventive screenings are covered by Medicare at no charge. However, if your doctor makes a diagnosis during the visit/service or orders diagnostic tests because you have distinct symptoms of a condition or a history of that condition, you may have additional costs. For example, if a doctor performs a colonoscopy and removes a polyp during the procedure, the colonoscopy is then considered diagnostic, and costs will apply.

Medicare Advantage Plans

Those who have a Medicare Advantage plan should not be charged for preventive services that are free for people with Original Medicare, as long as they see an in-network provider. Going out of the network means that charges will typically apply.

Not all preventive screenings are no charge. Highlighted below are various preventive screenings and their costs (if applicable). Be sure to review the “Medicare & You” handbook for details about the cost for specific services, or contact us (Backlink to the contact us section) in order to determine whether Medicare will cover these services, since some are covered only once every few years, and then only if you meet specific criteria.

No cost if the qualified primary care doctor accepts Medicare assignment
No cost for the tests. Medicare Part B covers blood tests for cholesterol, lipid, and triglyceride levels every five years.
No cost if the qualified primary care doctor accepts Medicare assignment. Medicare will cover one visit per year with your primary care doctor to reduce your risk for cardiovascular disease.
No cost for the lab pap smear test, specimen collection, or pelvic exam if the doctor accepts Medicare assignment.
No cost for the screening colonoscopy, the screening sigmoidoscopy, the screening fecal occult blood test, or multi-target stool DNA test if the doctor accepts Medicare assignment. There are costs for barium enemas, biopsies, or removal of lesions/growths during the same visit.
No cost if the doctor accepts Medicare assignment.
You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Diabetes training is designed to teach methods of coping with and managing diabetes, including healthy eating, active lifestyle, blood sugar monitoring, etc.
You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
If you ask for the test, you pay nothing if the qualified doctor or health care provider accepts assignment.
No cost if the doctor accepts Medicare assignment. People with Part B who have diabetes, kidney disease, have had a kidney transplant in the last 36 months or whose doctor refers them for the service are covered for nutrition therapy services.
No cost if the doctor accepts Medicare assignment. Those with Medicare Part B who have a body mass index of 30 or more are covered.
You pay 20% of the Medicare-approved cost for an annual digital rectal exam. The Part B deductible applies. In an outpatient setting you pay a co-payment. You pay nothing for an annual PSA blood test.
No cost if the doctor accepts Medicare assignment. Behavioral counseling sessions are covered only when provided by a primary care practitioner and take place in a doctor’s office or primary care clinic.
No cost if the doctor accepts Medicare assignment.
No cost if the doctor accepts Medicare assignment.

Get Expert Help Understanding Medicare

If you’re approaching eligibility for Medicare and have questions about the best option for you—Original Medicare versus Medicare Advantage—or you’re already a Medicare recipient but have questions about switching plans, the experts at CA Medicare can help. Call us today for answers to all your questions and assistance with Medicare enrollment.

Sources:
https://camedicare.com/what-is-medicare-gap-insurance/
http://www.medicare.gov/pubs/pdf/10050.pdf
https://camedicare.com/about/
http://www.medicare.gov/coverage/preventive-and-screening-services.html