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Medicare Provides
Preventive Services
There are many myths
about Medicare: many of which focus on what it covers and what it doesn’t.
Not surprisingly, older Americans are seemingly unaware that Medicare
covers a broad range of services to prevent disease, detect disease early
when it is most treatable and curable and manage disease so that
complications can be avoided.
"The U.S.
health care system is focusing on disease treatment as well as prevention
and wellness efforts," Robert Fusco, President, New Jersey
Association of Long Term Care Pharmacy Providers said in a recent release.
"Studies have shown that every $1 spent on prevention can save more
than $13 in health care cost. Preventing chronic medical problems will
save billons of dollars, while helping people to live longer, healthier
lives."
According to Centers
for Medicare and Medicaid Services (CMS) Prevention Web site, Medicare
began covering preventive services in 1981 with the pneumococcal
vaccination. Despite its long history of coverage, pneumococcal
vaccination rates are less than optimal, with 59.2 percent of non-Hispanic
Whites, 38.5 percent of Blacks and 30.2 percent of Hispanics reporting
ever receiving it.
Not surprisingly,
given all the myths surrounding Medicare, older adults are not receiving
all recommended preventive services, even with frequent visits to
physician offices. Reasons for this vary, but highlight the opportunity to
improve preventive care for older adults, CMS reports.
So what are some of
the screening and prevention efforts covered by Medicare? Of note,
individuals must be enrolled in Medicare Part B to get the prevention and
screening benefits.
 | "Welcome to
Medicare" physical exam.
According to Lita Epstein, author of The Complete Idiot’s Guide to
Social Security and Medicare, Medicare beneficiaries get a one-time
review of their health, as well as education and counseling about
preventive services, within the fist six months of coverage under
Medicare Part B. This exam is required and will include screenings,
shots and referrals for other care if needed. |
| Cardiovascular screenings.
Medicare covers tests for cholesterol, lipid and triglyceride levels
every five years. |
| Mammogram screenings.
Medicare covers mammograms once every 12 months for all women 40 and
older. Medicare also covers new digital technologies for mammogram
screening. |
| Pap test and pelvic exam.
If a woman has no evidence of cancer risk, she can get a Pap test and
pelvic exam once every 24 months. Women can have a test once every 12
months if they are high risk for cervical or vaginal cancer or if they
are of childbearing age and have had an abnormal Pap test in the past 36
months. This does include a clinical breast exam. |
| Colorectal Cancer Screening.
If you are age 50 or older, or are at high risk for colorectal cancer,
one or more of the following tests is covered: fecal occult blood test,
flexible sigmoidoscopy, colonoscopy and/or barium enema. The doctor and
the patient will determine the level of risk and the frequency of which
preventive screening tests should be used. |
| Prostate Cancer Screening.
Medicare covers a digital rectal exam and prostate specific antigen (PSA)
test once every 12 months for all men over age 50. |
| Diabetes Screening plus
services and supplies.
Available to those with any of the following risk factors: high blood
pressure, dyslipidemia, obesity or a history of high blood sugar.
Medicare also covers this test if you meet two or more of the following
characteristics: age 65 or older; overweight; family history of diabetes
(parents, brothers, sisters); and a history of gestational diabetes
(diabetes during pregnancy) or delivery of a baby weighing more than 9
pounds. Medicare plays for glucose monitors, test strips, and lancets as
well as diabetes self-management training. |
| Bone Mass Measurements.
Medicare covers these measurements once every 24 months (more often if
medically necessary) for people with Medicare at risk for osteoporosis. |
| Glaucoma Screening.
Medicare covers the test once every 12 months for people with Medicare
at high risk for glaucoma. The screening must be done or supervised by
an eye doctor who is legally allowed to do this service, according to
Epstein. |
| Shots/vaccinations.
Medicare covers the flu shot once a year in the fall or winter.
Beneficiaries can also get a Pneumococcal pneumonia shot. Medicare
covers Hepatitis B shots for people with Medicare at high or medium risk
for Hepatitis B. |
Of note, Medicare
beneficiaries must be aware of something called "assignment."
According to Epstein, when a doctor accepts assignment from Medicare, it
means he/she will submit the bill to Medicare and will be paid by Medicare
at Medicare's allowable rate for 80 percent of the treatment cost. The
patient is still responsible for his/her 20 percent co-pay of allowable
charges.
If a doctor does not
accept assignment, he/she still must submit the charges to Medicare, but
Medicare will not pay the doctor directly. The patient will receive all
payments from Medicare and the doctor needs to collect any money due
directly from the patient. Most doctors that don't accept assignment
expect full payment at the time of the appointment. Doctors who usually
take this stance want more for the treatment (procedure) than is allowed
by Medicare. So, if a patient decides to use a doctor that does not accept
assignment, he/she should be aware that the reimbursement from Medicare
may be less than the 80 percent of total cost. Going to a doctor that does
not accept assignment can become very expensive.
For more details about Medicare's
coverage of preventive services, including costs under the Original
Medicare Plan, call 800.MEDICARE or visit www.cms.hhs.gov/PrevntionGenInfo/
and www.medicarerxeducation.org/Guide%20to%20Preventative%20Servics.pdf.
January 2007— This column is
produced by the Financial Planning Association, the membership
organization for the financial planning community, and is provided by
McGuire & Co., LLC, a local member of the FPA.
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