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Medicare Provides Preventive Services

There are many myths about Medicare: many of which focus on what it covers and what it doesn't. Not surprisingly, older Americans are seemingly unaware that Medicare covers a broad range of services to prevent disease, detect disease early when it is most treatable and curable and manage disease so that complications can be avoided.

“The U.S. health care system is focusing on disease treatment as well as prevention and wellness efforts,” Robert Fusco, President, New Jersey Association of Long Term Care Pharmacy Providers said in a recent release. “Studies have shown that every $1 spent on prevention can save more than $13 in health care cost. Preventing chronic medical problems will save billons of dollars, while helping people to live longer, healthier lives.”

According to Centers for Medicare and Medicaid Services (CMS) Prevention Web site, Medicare began covering preventive services in 1981 with the pneumococcal vaccination. Despite its long history of coverage, pneumococcal vaccination rates are less than optimal, with 59.2 percent of non-Hispanic Whites, 38.5 percent of Blacks and 30.2 percent of Hispanics reporting ever receiving it.

Not surprisingly, given all the myths surrounding Medicare, older adults are not receiving all recommended preventive services, even with frequent visits to physician offices. Reasons for this vary, but highlight the opportunity to improve preventive care for older adults, CMS reports.

So what are some of the screening and prevention efforts covered by Medicare? Of note, individuals must be enrolled in Medicare Part B to get the prevention and screening benefits.

• "Welcome to Medicare" physical exam. According to Lita Epstein, author of The Complete Idiot's Guide to Social Security and Medicare, Medicare beneficiaries get a one-time review of their health, as well as education and counseling about preventive services, within the fist six months of coverage under Medicare Part B. This exam is required and will include screenings, shots and referrals for other care if needed.
• Cardiovascular screenings. Medicare covers tests for cholesterol, lipid and triglyceride levels every five years.
• Mammogram screenings. Medicare covers mammograms once every 12 months for all women 40 and older. Medicare also covers new digital technologies for mammogram screening.
• Pap test and pelvic exam. If a woman has no evidence of cancer risk, she can get a Pap test and pelvic exam once every 24 months. Women can have a test once every 12 months if they are high risk for cervical or vaginal cancer or if they are of childbearing age and have had an abnormal Pap test in the past 36 months. This does include a clinical breast exam.
• Colorectal Cancer Screening. If you are age 50 or older, or are at high risk for colorectal cancer, one or more of the following tests is covered: fecal occult blood test, flexible sigmoidoscopy, colonoscopy and/or barium enema. The doctor and the patient will determine the level of risk and the frequency of which preventive screening tests should be used.
• Prostate Cancer Screening. Medicare covers a digital rectal exam and prostate specific antigen (PSA) test once every 12 months for all men over age 50.
• Diabetes Screening plus services and supplies. Available to those with any of the following risk factors: high blood pressure, dyslipidemia, obesity or a history of high blood sugar. Medicare also covers this test if you meet two or more of the following characteristics: age 65 or older; overweight; family history of diabetes (parents, brothers, sisters); and a history of gestational diabetes (diabetes during pregnancy) or delivery of a baby weighing more than 9 pounds. Medicare plays for glucose monitors, test strips, and lancets as well as diabetes self-management training.
• Bone Mass Measurements. Medicare covers these measurements once every 24 months (more often if medically necessary) for people with Medicare at risk for osteoporosis.
• Glaucoma Screening. Medicare covers the test once every 12 months for people with Medicare at high risk for glaucoma. The screening must be done or supervised by an eye doctor who is legally allowed to do this service, according to Epstein.
• Shots/vaccinations. Medicare covers the flu shot once a year in the fall or winter. Beneficiaries can also get a Pneumococcal pneumonia shot. Medicare covers Hepatitis B shots for people with Medicare at high or medium risk for Hepatitis B.

Of note, Medicare beneficiaries must be aware of something called “assignment.” According to Epstein, when a doctor accepts assignment from Medicare, it means he/she will submit the bill to Medicare and will be paid by Medicare at Medicare's allowable rate for 80 percent of the treatment cost. The patient is still responsible for his/her 20 percent co-pay of allowable charges.

If a doctor does not accept assignment, he/she still must submit the charges to Medicare, but Medicare will not pay the doctor directly. The patient will receive all payments from Medicare and the doctor needs to collect any money due directly from the patient. Most doctors that don't accept assignment expect full payment at the time of the appointment. Doctors who usually take this stance want more for the treatment (procedure) than is allowed by Medicare. So, if a patient decides to use a doctor that does not accept assignment, he/she should be aware that the reimbursement from Medicare may be less than the 80 percent of total cost. Going to a doctor that does not accept assignment can become very expensive.

For more details about Medicare's coverage of preventive services, including costs under the Original Medicare Plan, call 800.MEDICARE or visit www.cms.hhs.gov/PrevntionGenInfo/ and www. medicare rxeducation.org/Guide%20to%20Preventative%20Servics.pdf.

January 2007 – This column was authored in cooperation with Financial Planning Association.