Tuesday afternoon I sat in my office with a cup of piping hot coffee and reviewed the onslaught of mailers and solicitations that had been piled on my desk. About halfway through my coffee I uncovered a solo postcard; a reminder that I am due for my annual “Well-Woman” exam, a once-a-year visit to a woman’s primary care provider for a general health check.
Not only did my doctor’s simple encouragement motivate me to make an appointment, it also stirred my curiosity.
Why did we go from a society that only visits the doctor when sick to one that visits regardless of our state of health. Furthermore, how does this affect my client, the Medicare beneficiary?
Why did we go from a society that only visits the doctor when sick to one that visits regardless of our state of health.
The most recent push for preventive medicine, i.e., annual check-ups, came with the passing of the ACA, the Affordable Care Act. Before the health care law, too many Americans did not get the preventive care they need to stay healthy or avoid and delay the onset of chronic disease. Often because of upfront costs associated with prevention care, Americans used preventive services at about half of the recommended rate. Yet chronic diseases, which are responsible for 7 out of 10 deaths among Americans each year and account for 75 % of the nation’s health spending, often are the most preventable.
Many individuals opposed this use of preventive care because of cost sharing. Cost sharing (including co-payments, co-insurance, and deductibles) reduced the likelihood that services would be used. For example, patients walk into their primary physician’s office and face a large bill for the screening, testing, or preventive service. Naturally people are inclined to avoid these services, especially when healthy, if they are being charged exorbitant amounts. However, these initial savings, e.g., avoiding the co-payments and coinsurance from an annual mammogram, leads to future costs when facing a chronic disease, e.g., breast cancer.
Cue the ACA, the health care legislation passed by Congress and signed into law by President Obama on March 23, 2010. The ACA helps make prevention affordable and accessible for all Americans. The ACA requires most health plans to cover recommended preventive services without cost sharing (no-copay, deductible, or coinsurance). In 2011 and 2012, 71 million Americans with private health insurance gained access to preventive services with no cost sharing because of the new law.
How Does this affect Medicare beneficiaries?
Through the ACA, certain recommended preventive services are free for people on Medicare. Medicare has also expanded its list of preventive services in the last few years. Covered Medicare individuals pay nothing for most of these preventive services.
Using these preventive services means future savings and better health for Medicare beneficiaries. Something we all want to achieve regardless of our age!
Therefore, I will leave you with a list of a dozen or so screenings and tests that are commonly prescribed by doctors. Enjoy the health, wealth, and knowledge!
“Welcome to Medicare” Preventive Visit– One-Time
An initial “Welcome to Medicare” preventive visit is included in Part B Covered Preventive Services.
During the first 12 months of Part B Coverage, newly-enrolled individuals will meet with a doctor or other Medicare-approved health care provider to develop a personalized plan to improve health, prevent disease, and encourage overall wellness.
There is no charge to the individual for this visit. Medicare pays the doctor or other care provider who accepts assignment. If additional tests are provided during the visit that are not covered under the preventive category, then coinsurance and the Part B deductible may apply.
Yearly “Wellness” Visit
A Part B-covered person may meet with a doctor or health care provider to update the wellness plan on an annual basis. A Health Risk Assessment will assist the provider in coordinating a good-health plan with the patient. Wellness visit protocols have been developed through years of medical research from the Centers for Disease Control and Prevention (CDC).
A “Wellness” visit is covered only when it has been 12 months since the “Welcome to Medicare” visit. A “Welcome to Medicare” visit is not a prerequisite to the first annual “Wellness” visit to the doctor.
Doctor and Other Health Care Provider Services
Medicare covers doctor services (outpatient or hospital inpatient) that are medically necessary or that are covered preventive services. Medicare also covers services provided by other health care providers, such as physician assistants, nurse practitioners, social workers, physical therapists, and psychologists. Some preventive services are provided at no cost; others are subject to the Part B deductible and a 20% copay.
Abdominal Aortic Aneurysm Screening
As part of the “Welcome to Medicare” preventive appointment, a referral will be necessary in order to receive a one-time abdominal aortic aneurysm screening. If the health care provider or the doctor who provides this screening accepts assignment from Medicare, then there is no cost to the patient.
Alcohol Misuse Counseling
Medicare covers one alcohol misuse screening per year. Pregnant women also qualify for alcohol misuse counseling. Up to four face-to-face counseling sessions are provided each year if a primary care doctor or primary care practitioner determines alcohol is being misused, provided the patient is cognizant and alert at the time. The counseling must be provided by a qualified primary care doctor or other primary care practitioner in a primary care setting. If the qualified doctor or practitioner accepts assignment, the sessions are provided at no cost.
Bone Mass Measurements (Bone Density)
This test checks to see if the patient is at risk for broken bones. It is covered once every 24 months (or more often for those who have medical necessity). There is no cost to the patient for this test if the doctor or health care provider accepts assignment from Medicare.
Breast Cancer Screening (Mammograms)
Mammograms to check for breast cancer once every 12 months are covered for all women 40 years old or older, and who qualify for Medicare. Medicare covers one baseline mammogram for women age 35-39. There is no cost to the patient for this screening if the doctor or health care provider accepts assignment from Medicare.
To help lower your risk for cardiovascular disease, Medicare will cover one visit per year with a primary care doctor in a primary care setting (like a doctor’s office). During this visit, the doctor may check your blood pressure, discuss aspirin use (if necessary), and give you tips to make sure you are eating well. There is no cost to the patient for this visit if the doctor or other qualified health care provider accepts assignment.
Medicare covers screening tests (every 5 years) that include blood tests to check cholesterol, lipid, lipoprotein, and triglyceride levels, and other tests for early detection of, or to identify a high risk, for developing cardiovascular disease. It costs the patient nothing for the tests, although 20% of the Medicare-approved amount may be charged in connection with the pre-test doctor’s visit.
Cervical and Vaginal Cancer Screening
Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the exam, Medicare also covers a clinical breast exam to check for breast cancer. These tests are covered once every 24 months. Tests for women at high risk for cervical or vaginal cancer, or who are of childbearing age and have had abnormal Pap test within the past 36 months, are covered for these tests once every 12 months (rather than 24 months). Patients pay nothing for the Pap lab test or specimen collection and nothing for pelvic and breast exams if the doctor or other health care provider accepts assignment from Medicare.
Colorectal Cancer Screening
Medicare covers colorectal cancer screenings in an effort to discover precancerous growths or to detect cancer early when treatment is most effective.
Medicare covers one depression screening per year. The screening must be completed in a primary care setting (like a doctor’s office) that can provide follow-up treatment and referrals. If the doctor or other qualified health care provider accepts assignment, the screening test is provided at no cost. However, the cost of the doctor’s visit itself is generally 20% of the Medicare-approved amount.
Medicare covers diabetes screenings if the patient has any of the following risk factors:
1) High blood pressure, 2) History of abnormal cholesterol and triglyceride levels, 3) Obesity, and 4) History of high blood glucose.
If an individual has a family history of diabetes or is overweight, tests may also be covered.
Based upon test results, an individual may be eligible for up to 2 diabetes screenings per year. If the health care provider or doctor accepts assignment then nothing is due.
Diabetes Self-Management Training
Medicare covers diabetes screenings if any of the following risk factors is present: 1) Health eating guidelines, 2) Exercise recommendations, 3) Medication instructions, 4) Self-monitoring blood sugar tests, and 5) Reducing risks of having diabetes.
In order to qualify for diabetes self-management training, an individual must have diabetes and have a written order from the doctor or other health care provider. The Part B deductible and 20% co-pay may apply.
Medicare covers flu shots one time per flu season in the fall or winter.
These tests are covered once every 12 months to individuals who are at high risk for glaucoma: 1) Diabetes, 2) A family history of glaucoma, 3) African Americans age 50 and older, 4) Hispanics age 65 or older, and 5) The eye doctor who does the testing must be approved by the state. A hospital copayment applies if a hospital outpatient service is used. The patient pays a 20% copay and the Part B deductible applies for the doctor’s visit.
Hepatitis B Shots
The following individuals are at medium or high risk for Hepatitis B: 1) Hemophilia. 2) End-Stage Renal Disease, and 3) Certain conditions that increase a risk for infection.
Medicare covers Hepatitis B shots for these individuals. There is no charge for this service from a doctor or other health care provider who accepts assignment.
Medicare covers HIV screening for individuals at increased risk for the infection, for pregnant women, and for anyone who asks for the test. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. There is no charge to the individual for the HIV screening.
Medical Nutrition Therapy Services
For those individuals who have diabetes or kidney disease or who have had a kidney transplant in the last 36 months and who have been referred to this therapy. Medicare will cover the costs. This care includes medical nutrition therapy and other related services.