Your Guide to Medicare Preventive Services and Screenings
We all know that preventive care is intended to prevent serious health conditions from sprouting in the future, potentially saving us thousands of dollars on healthcare costs and keeping our lives happy and healthy.
If you’re age 65 or older and enrolled in Medicare — or are under age 65 and Medicare eligible because you have a disability — this is the guide for you. But if you’re under age 65 and are looking for preventive services that are provided by traditional health insurance, go here for your guide to preventive care.
What’s included in this guide:
- Why are preventive services and screenings free?
- Medicare preventive visits
- The difference between preventive and diagnostic services
- Which Medicare preventive services are free?
- How to prepare for a preventive care appointment
Preventive health screenings are covered through Medicare Part B, which is the medical insurance portion of Original Medicare. If you are enrolled in a private Medicare Advantage plan — also known as Medicare Part C — because you wanted additional coverage than what Original Medicare provides, preventive services are still free as long as the beneficiary visits an in-network provider. However, there are some Medicare Advantage plans that may require a small copayment for certain preventive services if you see an out-of-network provider. In this case, it would be wise to consult with your private insurance company to discuss costs before seeing your doctor.
Why Are Preventive Services and Screenings Free?
You may or may not be surprised to learn that many older adults do not take advantage of the free, lifesaving preventive services provided through his or her Medicare coverage. In fact, “fewer than half of adults age 65 years or older are up-to-date with core preventive services despite regular checkups,” according to the Centers for Disease Control and Prevention.
Preventive services like mammograms and colorectal cancer screenings can significantly reduce cancer deaths, but many people used to opt out of receiving these screenings because of the cost. In 2010, when the Affordable Care Act was passed, it made certain preventive services 100 percent free as a way to encourage beneficiaries to prioritize their health without the concern of paying out-of-pocket fees. As long as your doctor or healthcare provider accepts Medicare assignment — meaning he or she accepts the Medicare-approved amount as full payment for covered services — you will not have to pay out of pocket for any preventive services.
Medicare Preventive Visits
Once you enroll in Medicare, you will have the opportunity to benefit from many preventive care services that are at no cost to you. Several preventive screenings, tests, and services you may be eligible for are determined during key doctor’s visits, including:
- A Welcome to Medicare visit in which your doctor or healthcare provider looks at your medical and family history, your current health condition, and any prescriptions you currently have. During this one-time visit, your doctor will also check your blood pressure, weight, height, and vision. Based on all of the aforementioned information, your doctor will then decide which free preventive services should be ordered for you. You’ll also receive a checklist with all the free services that are available to you. This visit must be within the first 12 months of your Medicare enrollment.
- Annual wellness visits in which your doctor creates (during the initial annual wellness visit) or updates (during subsequent annual visits) your 5- to 10-year preventive schedule based on your health needs via a health risk assessment (HRA) questionnaire. The HRA is used to determine your physical and mental health, and your functional level of safety. Identifying Alzheimer’s or dementia symptoms are also addressed during annual wellness visits.
Your doctor or healthcare provider may give health advice or referrals to outside services during any Medicare preventive visit based on your preventive service needs to keep you healthy. Similar to free preventive services, you don’t have to pay for any of your wellness visits when you use a healthcare provider who accepts Medicare assignment. Wellness visits are not the same as traditional yearly physicals.
The Difference Between Preventive and Diagnostic Services
Preventive services are meant to prevent you from getting sick. They can also help determine if you are at risk for diseases or conditions early on so that you can take preventive steps before it’s too late. Services include screenings, vaccinations, and counseling. Many preventive services are completely covered under Medicare at no cost to the enrollee.
There are some preventive services, however, that are not free. These include:
- Glaucoma screenings
- Diabetes self-management training
- Prostate cancer screening by digital rectal examination
- Colorectal screening by barium enema
Cost-sharing preventive services require the beneficiary to pay 20 percent of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you will also have to pay a copayment.
Diagnostic services are for a condition or symptoms you already have. These are cost-sharing services that require an out-of-pocket expense, which could include a deductible, copay, or coinsurance. In other words, diagnostic services are not free to Medicare beneficiaries.
Which Medicare Preventive Services Are Free?
Different from free preventive care screenings provided by traditional health insurance, Medicare provides free screenings, tests, vaccinations, and counseling services that are recommended for people who are age 65 and older, such as bone density tests. There are also free services for those who are under 65 but are still qualified to enroll in Medicare.
Below is a comprehensive list of all the services available to Medicare beneficiaries.
|Preventive Service||What is covered?||Who is eligible?|
|Abdominal Aortic Aneurysm Screening||A one-time ultrasound||Medicare beneficiaries with their doctor’s referral received during their Welcome to Medicare exam; anyone at risk|
|Alcohol Misuse Counseling||One screening and 4 brief face-to-face counseling sessions per year||Medicare beneficiaries who are not alcohol dependent but use alcohol|
|Bone Mass Measurement (bone density)||One test every 24 months or more frequently if determined medically necessary||All Medicare beneficiaries at risk for osteoporosis|
|Breast Cancer Screenings||Annual screenings include breast exams and mammograms||Medicare beneficiaries who are women age 40 or older; women with part B age 35-39 qualify for one baseline screening|
|Cardiovascular Screenings||Blood tests to check cholesterol, lipid, and triglyceride levels every 5 years, when ordered by a doctor||All Medicare beneficiaries|
|Cardiovascular Behavioral Therapy||One session per year with your primary care practitioner||All Medicare beneficiaries|
|Cervical and Vaginal Cancer Screenings||Pap tests and pelvic exams once every 24 months or once every 12 months if you’re at high risk for cervical or vaginal cancer||All women with Medicare|
|Colorectal Cancer Screenings||Flexible sigmoidoscopy every 48 months for most people 50 or older; colonoscopy every 24 months if you’re high risk, or every 120 months if you aren’t at high risk; fecal occult blood test every 12 months||All Medicare beneficiaries 50 or older; those under 50 are only eligible for a colonoscopy|
|Depression Screening||One screening per year in a primary care setting||All Medicare beneficiaries|
|Diabetes Screening||Up to 2 fasting blood glucose tests||Medicare beneficiaries who are at high risk for diabetes|
|Hepatitis C Screening Test||One test only, or yearly screenings for people at high risk||Medicare beneficiaries who are at high risk because of past or present illicit injection drug use, those who had a blood transfusion before 1992, and those born between 1945-1965|
|HIV Screening||One test every 12 months||All Medicare beneficiaries|
|Lung Cancer Screening||One screening with Low Dose Computed Tomography (LDCT) per year||Medicare beneficiaries who are ages 55-77, are asymptomatic, are a current smoker or quit smoking within the last 15 years, smoked a pack a day for at least 30 years, and get a written order from their physician|
|Medical Nutrition Therapy||Three hours of therapy for the first year and two hours for years thereafter of dietary counseling||Medicare beneficiaries with diabetes or other chronic diseases|
|Obesity Screening and Counseling||Behavioral counseling sessions to help you lose weight||Medicare beneficiaries with a body mass index (BMI) of 30 or more|
|Prostate Cancer Screenings||Prostate specific antigen test once every 12 months||All men over age 50 with Medicare|
|Sexually Transmitted Infections Screening||Screenings for chlamydia, gonorrhea, syphilis and/or Hepatitis B once every 12 months||All Medicare beneficiaries at risk for an STI|
|Tobacco Use Cessation Counseling||Up to 8 face-to-face visits in a 12-month period||All Medicare beneficiaries who use tobacco|
|Vaccinations||Flu shots, pneumonia shots, and Hepatitis B||All Medicare beneficiaries|
How to Prepare for a Preventive Care Appointment
As you read earlier, there are many preventive care services that are free but there are a few that have an out-of-pocket fee. In order to be completely aware of what is free and what isn’t, here are 7 questions that are worth asking your doctor or healthcare provider when scheduling an appointment:
- Does Medicare cover the preventive service?
- Does my doctor or healthcare provider accept Medicare assignment?
- Is there an out-of-pocket expense for this visit?
- Is there an out-of-pocket expense for the preventive service?
- Will I receive any services that require an out-of-pocket expense during this visit?
- Will I receive any services in a setting that requires an out-of-pocket expense?
- Can I receive the preventive service in a setting that does not require an out-of-pocket expense?
Click here to download the 7 questions you should ask.