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Guide to Medicare’s Preventive Health Benefits SHIBA Statewide Health Insurance Benefits Advisors A free, unbiased service of the: 1 November 2013
Guide to Medicare’s Preventive Health Benefits
SHIBAStatewide Health Insurance Benefits Advisors
A free, unbiased service of the:
1November 2013
SHIBA mission
SHIBA provides free, unbiased information about health care coverage and access to help improve the lives of all Washington state residents. We cultivate
community commitment through partnership, service and volunteering.
2November 2013
How can I start?
Do physical activitiesEducate yourself
Avoid tobacco
Get a preventive exam
Keep a healthy weight 3November 2013
Medicare’s preventive benefits (are you at risk?)
Talk to your doctor or medical provider Your doctor may identify a health risk
from your free screening If so, there may be a charge for the
follow-up diagnostic test
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Why get the free screening?
If you seek medical care AFTER you have a problem or become sick:
Damage has already occurred Treatment can be very costly Your quality of life suffers
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Preventive services
Prevention is covered under Medicare Part B
Most preventive services are free – however some charge a coinsurance
Check with your provider to make sure they accept Medicare
“Taking action early to prevent disease, minimize complications, and contain costs”
-- Wellsource, Inc.
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Risk factors for health
Individual/family medical history Lifestyle behaviors & choices Age Gender Multiple risk stacking
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Types of preventive services
Health screening/exams Counseling Education Immunizations
Diagnostic tests may be ordered by the medical provider if you’re at risk, but these tests may have an out-of-pocket cost.
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After you’re eligible for Part B
Get your Welcome to Medicare Preventive visit during your first 12 months of Part B coverage
What occurs during this visit – your doctor: Reviews your medical and family history Assesses any risk factors you may have Identifies risk factors that may make it necessary to get follow-up
tests that have out-of-pocket costs
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Welcome to Medicare Preventive visit
No cost if medical provider accepts Medicare
November 2013
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After you’re eligible for Part B
The yearly Wellness visit takes place after your first 12 months of Part B eligibility (not as comprehensive)
Medicare covers this visit once every 12 months Anyone with Medicare is eligible You pay nothing for the visit, unless you get
additional tests or services that aren’t covered
Wellness visit
No cost if medical provider accepts Medicare
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Abdominal Aortic Aneurysm Screening (AAA)
Covered one time by a doctor referral as a result of your “Welcome to Medicare” visit
You must have a family history of AAAOR
Be a male age 65 to 75 who’s smoked at least 100 cigarettes in your lifetime; and
You’ve never had an AAA ultrasound screening paid for by Medicare
No cost if medical provider accepts Medicare
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Alcohol misuse counseling
This covers: One screening per year Positive screens can receive 4 face-to-face
counseling sessions per year (in a primary care setting)
Eligible people include adults and pregnant women who use alcohol
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No cost if medical provider accepts Medicare
November 2013
Bone mass measurements
Test covered once every 24 months (more often if medically necessary)
To qualify you must be at risk for osteoporosis & meet 1 of the 5 criteria:1. Female being treated for estrogen-deficiency; OR
an x-ray reveals back bone abnormalities; OR2. You get steroid treatments; OR 3. You have hyperparathyroidism; OR4. You take a osteoporosis drug
No cost if medical provider accepts Medicare
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Cardiovascular screenings
Tests are covered every 5 years and include:
Total cholesterol test Cholesterol test for high density lipoproteins (HDLs) Triglyceride test Lipid panel tests
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No cost if medical provider accepts Medicare
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Colon cancer screenings (colorectal)
How often you can get these tests:
Fecal Occult Blood Test: Once every 12 months Flexible Sigmoidoscopy (FS): Every 24 months or 120
months for low-risk people Colonoscopy screening: Every120 months
Every 24 months for high-risk people or 48 months after FS test
There are costs for these tests – check with your provider
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Depression screening
Covers one screening a year Must be done in a primary care
setting that can provide follow-up treatment and referrals
No cost if medical provider accepts Medicare
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Diabetes screenings
Screenings are covered if you have these risk factors: High blood pressure History of abnormal cholesterol and triglyceride levels Obesity History of high-blood sugar
And you are two or more of the following: Over age 65 Overweight Family history of diabetes Had diabetes during pregnancy
No cost if medical provider accepts Medicare
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Diabetes self-management training
You must be at risk for diabetes implications
You must have a written order from a medical provider
You pay 20% of Medicare-approved amount after you meet Part B deductible
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Flu, Hepatitis B and Pneumonia shots
Flu shots: One per flu season starting in the fall Hepatitis B shots: For people with medium or high risk;
comes in a series of three for complete protection Pneumonia shots: You can have any time of year, most
people only need one in a lifetime High risk people can get a pneumonia booster every 5 years
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No cost if medical provider accepts Medicare
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Glaucoma tests
20No cost if medical provider accepts Medicare
Medicare covers a Glaucoma screen by a doctor once every 12 months, including: Dilated eye exam with an eye pressure measurement A direct opthalmascope exam
Eligible people include: You’re at high risk for diabetes You’re African American over age 50 You’re Hispanic and age 65 or older
Costs: You pay 20% of Medicare-approved amount after you meet the yearly
Part B deductible
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Medical nutrition therapy
Covers people with: Diabetes Kidney disease Kidney transplant within the last 3 years
Therapy must be prescribed by a doctor Benefits of initial lifestyle & nutrition assessment:
Nutrition counseling Lifestyle management information (diet) Diet management follow-up visits
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No cost if medical provider accepts Medicare
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Cervical & vaginal cancer screenings
High-risk women: Covers 1 Pap test & Pelvic exam/year
Low-risk women: Covers 1 exam every 2 years for cervical cancer (breast exam
included)If medical provider accepts Medicare, there’s no cost for pap lab test & specimen collection, or pelvic & breast exams
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Prostate cancer screenings
Covers men over age 50 for a: Digital rectal exam & Prostate Specific Antigen (PSA) once
every 12 months
Costs: For PSA, no cost For digital rectal exam, you must meet the Part B deductible,
and you’ll have to pay a deductible and coinsurance
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Obesity screening & counseling
Medicare covers if your body mass index is 30 or more
Talk to your provider for more details
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HIV screenings
Covers an HIV test once every 12 months or up to 3 times during a pregnancy
People with Medicare may request the test. You must be: Pregnant At increased risk for the infection
No cost for the test, but you must pay 20% of the Medicare-approved amount for the doctor visit
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Smoking cessation
To qualify, you must use tobacco and be on Medicare Covers 8 face-to-face sessions to help you stop smoking
during a 12-month period A qualified doctor or other Medicare-recognized provider
must provide the sessions You pay nothing for the counseling sessions
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SHIBA volunteer opportunities
Love to learn and help people Like problem-solving Don’t mind paperwork or computer work Are organized Can attend regular training
You might be interested in becoming a volunteer if you:
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Want more information?
Publications: Your Guide to Medicare Preventive Services, CMS
Pub #10110 Staying Healthy, CMS Pub #11100 Understanding Your Health Insurance Options, SHP
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Medicare preventive benefits tracking
To track your benefits, use the My Medicare Preventive Benefits Checklist – get a copy at:
Web: http://www.medicare.gov Call: 1-800-MEDICARE (1-800-633-4227) TTY users call: 1-877-486-2048
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Need help with other insurance questions?
The Office of the Insurance Commissioner can also help you with questions, information, and complaints about all
types of insurance, such as:
Call our Insurance Consumer Hotline
1-800-562-6900Check out our Consumer Toolkit at
www.insurance.wa.gov/consumers
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• Annuities• Health• And more!
November 2013
