Medicare
Preventive Services
Module 7
Session Topics
* What is covered
- Why preventive services are important
- Who is eligible
- How much you pay
* Information sources
Living a Healthy Lifestyle
* Eat well
* Exercise
* Keep a healthy weight
* Don't smoke
* Get preventive services to
- Delay or lessen the effects of diseases
- Find disease early
- Get shots to keep you from getting dangerous infections
Medicare Preventive Services
* Medicare coverage based on
- Age
- Gender
- Medical history
* Covered by
- Part B of Original Medicare
- Medicare Advantage and other Medicare plans
Covered Screening and
Preventive Services
* One time "Welcome to Medicare" physical exam
* Physical Exam (yearly "Wellness Exam") Starts 2011
* Abdominal aortic
aneurysm screening*
* Bone mass measurement
* Cardiovascular disease screenings
* Colorectal cancer screenings
* Diabetes screenings
* EKG Screening*
* Flu shots
* Glaucoma tests
* Hepatitis B shots
* HIV Screening
* Mammograms (screening)
* Pap test/pelvic exam/clinical breast exam
* Prostate cancer screening
* Pneumococcal shots
* Smoking cessation
What You Pay in 2010
* Original Medicare
- Generally 20% after Part B deductible
• Medigap or other policies may pay the 20%
• May have to pay more if
o Provider does not participate in Medicare
o Provider does not accept assignment
• Some services cost less
* Medicare Advantage or other Medicare plan
- May have copayment
Elimination of Part B Deductible and Coinsurance Requirements in 2011
* Starting January 1, 2011
* You pay nothing for most preventive services
- If you get them from a doctor or other health care provider who accepts assignment
* Services affected must have an "A" or "B" rating
- By the United States Preventive Services Task Force
One Time "Welcome to Medicare"
Physical Exam
* Covered within first 12 months of having Part B
- Height, weight and body mass index
- Blood pressure and end of life planning
- Education, counseling, and referrals (e.g., EKG)
* In Original Medicare you pay
- 20% of the Medicare-approved amount
- No deductible
- Effective January 1, 2011, you pay no
copayment if doctor accepts assignment
Abdominal Aortic Aneurysm Screening
* Abdominal aortic aneurysms (weak area bulges)
* Risk factors include
- A family history of abdominal aortic aneurysms
- Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime
* Ultrasound screening covered by Medicare
- Referral from the "Welcome to Medicare" physical exam
- You pay 20% of the Medicare-approved amount with no Part B deductible
- No deductible or copayment starting
January 1, 2011
New Annual Wellness Visit
* Effective January 1, 2011
* Annual Wellness Visit
- Comprehensive health risk assessment
- Personalized prevention plan
- Health advice and referral to education and preventive counseling
- No copayment or deductible
- Available every 12 months (after first 12 months of initial Part B coverage)
o But not within 12 months of receiving either a "Welcome to Medicare" physical exam or another Annual Wellness visit
Bone Mass Measurement
Cardiovascular Disease Screening
* Blood test for early detection
- Heart disease
- Stroke
* Tests for levels of
- Cholesterol
- Triglycerides
- Lipids
* Covered every 5 years
* In Original Medicare you pay nothing
Cardiac Rehabilitation
* Medicare covers cardiac programs that include
- Exercise
- Education
- Counseling certain patients with a doctor's referral
- Intensive cardiac rehabilitation programs
* You pay 20% of the Medicare-approved amount
- If you get the services in a doctor's office
• No change in 2011
* You pay a copayment In a hospital outpatient setting
Colorectal Cancer Screening
* Helps find precancerous growths
- Helps prevent or find cancer early
* One or more of the following tests may be covered
- Fecal Occult Blood Test
- Flexible Sigmoidoscopy
- Colonoscopy
- Barium Enema
Diabetes Risk Factors
* Diabetes is a chronic condition
- Body does not produce or properly use insulin
* Risk Factors
- High blood pressure
- High cholesterol
- Obesity
- History of high blood sugar
- At least two of the following
• Age 65 or older, overweight, family history of diabetes, or past gestational diabetes or having a baby over 9 pounds
Diabetes Management
* May be able to avoid or delay complications
* You can manage your diabetes
- Test blood sugar regularly
- Eat a proper diet
- Exercise regularly
- Take medication as prescribed
Diabetes Screening
* Testing for people at risk
* Includes fasting blood glucose test
* Talk with your doctor about frequency
- Up to twice in a 12-month period
* Original Medicare
- No deductible or coinsurance
Covered Diabetes Services
* Screening for all at risk
* For people with diabetes
- Self-management training
- Medical nutrition therapy
- Blood sugar testing supplies
• Insulin and related supplies
- Special eye exams
- Hemoglobin A1c tests
Covered Diabetes Services
* People with diabetes who need them
- Insulin pumps
- Special foot care
- Therapeutic shoes
* In Original Medicare you pay
- 20% after Part B deductible
- No change in 2011
* Medicare Coverage of Diabetes Supplies
& Services (CMS Pub. 11022)
Glaucoma Examination
* Glaucoma is caused by increased eye pressure
- May gradually lose sight without symptoms
* Protect yourself with screening eye exam
* Covered if high risk once every 12 months
* In Original Medicare you pay
- 20% of the Medicare-approved amount
• Part B deductible applies for the doctor services
- A copayment in a hospital outpatient setting
- No change in 2011
HIV Screening
* Medicare covers HIV screening for people
- Who are pregnant or at increased risk for the infection
- Includes anyone who asks for the test
* Covered once every 12 months
- Up to 3 times during a pregnancy
* No cost for the test
- Generally you pay 20% of the Medicare-approved amount
for the doctor's visit
- No deductible or copayment for the test
- No change in 2011
Pap Test and Pelvic Exam
with Clinical Breast Exam
* Risk factors for some cancers in woman include but aren't limited to
- Abnormal Pap test
- Human papilloma virus (HPV)
* Medicare covers
- Pap test to help find cervical and vaginal cancer
- Screening pelvic exam to help find fibroids/ovarian cancers
- Clinical breast exam (another way to look for breast cancer)
Pap Test and Pelvic Exam
with Clinical Breast Exam
* Covered for all women with Medicare
- Once every 24 months
- Once every 12 months if
• At high risk for cervical or vaginal cancer
• Childbearing age and abnormal Pap test in the past 36 months
Pap Test and Pelvic Exam
with Clinical Breast Exam
* In Original Medicare you pay
- Nothing for Pap lab test
- 20% for Pap test collection, pelvic exam,
and clinical breast exam
- No Part B deductible
- No copayment starting January 1, 2011
Prostate Cancer Risks
* Risk increases with age
- Age 45 - 1 in 2,500
- Age 50 - 1 in 476
- Age 55 - 1 in 120
- Age 60 - 1 in 43
- Age 65 - 1 in 21
- Age 70 - 1 in 13
- Age 75 - 1 in 9
* Ethnicity risk
* Hereditary risk
Prostate Cancer Screening
* Covered
- For all men with Medicare
- Beginning the day after 50th birthday
* Tests include
- Digital rectal exam
- PSA blood test
• Prostate-specific antigen
* In Original Medicare you pay
- Nothing for the PSA blood (lab) test
- 20% after Part B deductible for digital rectal exam
• No change in 2011
Breast Cancer and Mammography
* Breast cancer in women in U.S.
- Most commonly diagnosed non-skin cancer
- Second leading cause of cancer death
- Risk increases with age
- Successfully treated when found early
* Mammogram
- Checks for abnormal breast tissue
- Coverage includes digital technology
Screening Mammogram
* Covered for all women with Medicare
- One baseline mammogram age 35 to 39
- Once a year starting at age 40
* In Original Medicare you pay
- 20% coinsurance
- No Part B deductible
- No deductible or copayment starting
January 1, 2011
Diagnostic Mammogram
* Used when there are clinical findings
- On physical exam
- Abnormal screening mammogram
* Medicare covers as many as needed
- Also covered for men
* Different payment rates if diagnostic mammogram
Smoking Cessation
* Quitting gives significant health benefits
- Even older adults who smoked for years
* When services are covered
- If you have an illness caused/complicated by tobacco use
- If you take medication affected by tobacco use
Smoking Cessation Services
* Cessation counseling
- Up to 8 sessions per year
- Inpatient or outpatient
- Intermediate or intensive
* In Original Medicare you pay
- 20% after Part B deductible
• No change in 2011
* Medicare Part D prescription drug coverage
- Can help pay for drug therapy
• Nicotine patches, for example
Influenza ("Flu") Shot
* Flu can lead to pneumonia
- Can be dangerous for people 50 and over
* Flu viruses are always changing
- Shot updated for most current flu viruses
* Flu shot covered for all people with Medicare
* Once each flu season protects for about a year
* In Original Medicare you pay
- No deductible or copayment
H1N1 Flu Vaccine
* H1N1 flu is caused by a new strain of influenza virus
* Risk factors not as high for those over 65
- Higher risk for those with certain disabilities
* Medicare covers administration of the H1N1 flu shot
- You can't be charged for the vaccine (providers get it free)
- You pay nothing if provider accepts assignment
- Part B deductible and coinsurance don't apply
• To the vaccine or its administration
* You should still get the seasonal flu shot
Pneumococcal Pneumonia Shot
* Pneumonia is inflammation in the lungs
- Caused by bacteria (streptococcus pneumoniae)
* One shot could be all you ever need
* All people with Medicare are eligible
* In Original Medicare you pay
- No deductible or copayment
Hepatitis B Shots
* Serious disease (virus attacks the liver)
- Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, or death
* Covered for medium to high risk
- End-stage renal disease and hemophilia
- Condition that lowers resistance to infection
* In Original Medicare you pay
- 20% after Part B deductible
- No deductible or copayment starting
January 1, 2011
Medicare Education Benefit
* People with Stage IV chronic kidney disease
- Have advanced kidney damage and
- Will likely need dialysis or a kidney transplant soon
* Medicare Part B covers
- Up to six sessions of kidney disease education services if your doctor refers you for the service
* Provided to help prevent or delay the need for dialysis
- You pay 20% of the Medicare-approved amount, and the Part B deductible applies
• No change in 2011
Exercise
A. Your risk for osteoporosis is higher if you
* Are a man
* Are African-American
* Have a low-calcium diet
* Are overweight
Exercise
B. Medicare provides annual coverage for glaucoma screening for people with Medicare in the following high-risk categories
* Individuals who have diabetes
* Individuals who have a family history of glaucoma
* African-Americans age 50 and over
* Hispanics age 65 and older
* All of the above
Exercise
C. The best time to get a flu shot is in January or February
* True
* False
If You Want to Know More…
* Centers for Medicare & Medicaid Services
- Medicare Preventive Services, Pub. 10110
- Medicare & You handbook, Pub. 10050
- Your Medicare Benefits, Pub. 10116
- 1-800-MEDICARE (1-800-633-4227)
• TTY 1-877-466-2048
- www.medicare.gov
• http://mymedicare.gov/
If You Want to Know More…
* Local State Health Insurance Assistance Program (SHIP)
- Phone number in Medicare & You handbook
* American Cancer Society
- www.cancer.org
- 1-800-ACS-2345
If You Want to Know More…
* Cancer Information Service
- Live Help link at www.cancer.gov
- 1-800-4CANCER (TTY users call 1-800-332-8615)
* Centers for Disease Control and Prevention
- www.cdc.gov
* HHS tobacco cessation resources
- www.surgeongeneral.gov/tobacco