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The Centers for Disease Control and Prevention (CDC) reports that 90% of all healthcare costs in the United States are related to the treatment of chronic conditions.1 Many of these conditions are considered preventable and avoidable.
The good news for Medicare beneficiaries is that Medicare covers a number of preventive screening services that make early diagnosis and treatment possible.
What’s more, many beneficiaries can receive these screenings at low cost or no cost thanks to the Affordable Care Act, which eliminated cost sharing for a long list of Medicare preventive services.
Here’s a list of the most common preventive services; the criteria that allows many beneficiaries to receive them with no cost sharing; and an explanation of when beneficiaries may be required to pay the Medicare Part B deductible and coinsurance for these services.
Medicare Part B covers a number of vaccines without cost sharing if your healthcare provider accepts assignment, which means the provider agrees to charge you no more for their services than the Medicare-approved deductible and coinsurance amount.
Vaccines covered by Medicare Part B – with no cost sharing – include: 2
With the exception of the rabies vaccine and tetanus shots administered after an injury (see below), Medicare Part D covers other vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).3 Thanks to the Inflation Reduction Act, there is no longer any cost-sharing for vaccines covered under Medicare Part D.
The following are vaccines covered by Medicare Part D.
Medicare Part B covers certain vaccines only after you have had an exposure that increases your risk for infection. In these cases, you will be required to pay a 20% coinsurance.
Not everyone is aware of the many preventive services Medicare has to offer. Centers for Medicare & Medicaid Services (CMS) recognizes this and has provided opportunities for beneficiaries to learn about screenings and vaccinations during a visit with a healthcare provider.
It is important to know that these wellness visits are intended to review your medical history and to plan for appropriate preventive care. These visits do not include a complete physical exam.
According to the American Cancer Society, as many as 2 million people in the United States will be diagnosed with cancer in 2024 alone.9 Detecting cancer earlier allows people to be treated sooner and can hopefully prevent complications and even deaths from the disease.
Whether or not you will pay cost sharing for any of these services depends upon whether the service is a screening test or a diagnostic test. Screening tests – performed on people who do not have signs or symptoms of disease – may not require cost sharing. Diagnostic services – performed when there are symptoms or abnormal findings, or more frequently than the recommended screening tests – typically require cost-sharing.
As an example, a patient who receives a mammogram performed for screening purposes would not have to pay cost sharing. However, a mammogram to evaluate a lump in that patient’s breast would be considered a diagnostic test – and would require cost sharing.
In a similar way, a colonoscopy or flexible sigmoidoscopy can be covered with no cost-sharing if performed at the screening intervals covered by Medicare. But if a polyp is found and removed, the patient will pay 15% of the Medicare-approved amount for the facility fee and the doctor’s services.10
Medicare Part B coverage includes preventive screening services such as:
Medicare Part B offers a number of other preventive care screenings. Here’s a list of the screenings, how they’re covered and whether you’ll be required to pay a deductible or coinsurance.
The Centers for Disease Control and Prevention reports that more than 38 million people in the United States have diabetes and nearly 98 million have prediabetes. The condition can lead to complications that involve the heart, kidneys, nerves, eyes, and more. To decrease the number of people who progress from prediabetes to diabetes, Medicare has developed a behavioral health program that’s free for beneficiaries who qualify.13
The Medicare diabetes prevention program spans 12 months and can be completed only once. During the first six months, you can attend up to 16 weekly group sessions. In the second six months, you can attend monthly sessions. The group will be led by a healthcare professional or coach that will provide education about diabetes and motivate you toward lifestyle changes like diet, exercise, and weight management that can help to decrease your risk for diabetes.
This program is available with no cost sharing to you if you have had elevated blood sugars in the past 12 months but have not otherwise been diagnosed with diabetes (meaning you have a hemoglobin A1C between 5.7-6.4%, a fasting blood sugar between 110 and 125, or an oral glucose tolerance test with blood sugars between 140 to 199 after 2 hours). You must also have a body mass index (BMI) greater than 25 (greater than 23 if you are Asian) and not have end-stage renal disease (kidney disease that requires dialysis or a transplant).
Falls increase the risk for injury and debility. As part of the “Welcome to Medicare” preventive visit and “Annual Wellness Visit,” Medicare provides a fall risk assessment. However, beneficiaries who have concerns about falls and have already had these annual visits can schedule an appointment for an evaluation. That evaluation will be subjected to the Medicare Part B deductible and 20% coinsurance.
Many of the listed Medicare preventive services are provided to beneficiaries with no cost sharing, but there are times beneficiaries have to pay toward the Part B deductible or pay the Part B 20% coinsurance.
One way to reduce these out-of-pocket costs is to enroll in a Medicare Supplement Insurance plan, also known as Medigap. Medigap plans A, B, C, D, E, F, G and M pay the full Medicare Part B coinsurance amount while plans K, L, and N pay a portion of the coinsurance.14
Only Medigap plans C and F cover the Part B deductible, but these plans are not available for anyone who became eligible for Medicare on or after January 1, 2020.
Medicare preventive screenings and services |
|||
---|---|---|---|
Type of screening | Preventive screening test | Free (no cost sharing)? | Cost sharing? |
Cancer | |||
Breast: clinical exam | Yes | ||
Breast: mammogram | Yes | 20% coinsurance* | |
Cervical: Pap smear | Yes | ||
Cervical: HPV screening | Yes | ||
Colon: Barium enema | 20% coinsurance | ||
Colon: colonoscopy | 15% coinsurance for polyp removal and facility fee* | ||
Colon: flexible sigmoidoscopy* | Yes | 15% coinsurance | |
Colon: fecal occult testing | Yes | ||
Colon: multi-target stool DNA tests | Yes | ||
Lung: low-dose CT scan | Yes | ||
Prostate: digital rectal exam | Yes | Part B deductible and 20% coinsurance | |
Prostate: PSA test | Yes | ||
Vaginal/pelvic: pelvic exam | Yes | ||
Cardiovascular | |||
Abdominal aneurysm screening | Yes | ||
Lipid screening | Yes | ||
Counseling | |||
Alcohol misuse counseling | Yes | ||
Depression counseling | Yes | ||
Obesity counseling | Yes | ||
Smoking cessation | Yes | ||
Diabetes | |||
Diabetes screening | Yes | ||
Diabetes prevention program | Yes | ||
Diabetes self-management training | Yes | Part B deductible and 20% coinsurance | |
Medical nutrition | Yes | ||
Infection | |||
Hepatitis C | Yes | ||
HIV | Yes | ||
Sexually transmitted disease | Yes | ||
Vaccines | |||
COVID, influenza, pneumonia, hepatitis B, shingles, TDaP | Yes | ||
Rabies, tetanus | 20% coinsurance | ||
Wellness | |||
Welcome to Medicare visit | Yes | ||
Annual wellness visit | Yes | ||
Other | |||
Glaucoma screening | Part B deductible and 20% coinsurance | ||
* These services are free if they are covered as screening tests but require a coinsurance if they are performed for diagnostic purposes. |
Tanya Feke, M.D. is a licensed, board-certified family physician living in New Hampshire. As a practicing primary care physician in Connecticut and an urgent care physician in New Hampshire for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an expert in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authored Medicare Essentials: A Physician Insider Reveals the Fine Print. Her analysis of Medicare issues is frequently referenced by the media and she is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.
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