Medicare Minute: Medicare Preventive Services

What is preventive care?

Preventive care is the care you receive to prevent illness, detect medical conditions, and keep you healthy. During this Medicare Minute, we’ll look at Medicare’s coverage of preventive services and review the screening, vaccines, and counseling that can help you stay on top of your health. A quick reference handout is available for download that will include everything covered in this blog post and more.

Medicare Part B covers many preventive services with no cost-sharing, as long as you meet the eligibility requirements and follow the guidelines below.

Is it covered by Medicare?

Preventive services recommended by the U.S. Preventive Services Task Force are covered with zero cost-sharing, so you will not owe any deductible or coinsurance when you receive them. You can find a list of those services on Medicare.gov’s page on Preventive & Screening Services. You can also call 1-800-MEDICARE or read your Medicare & You handbook for a full list.

Do I meet the coverage criteria?

For many of the covered preventive services, you have to meet certain criteria based on your age, sex, or certain risk factors. Your health care provider should be able to tell if you qualify.

Am I seeing the right kind of provider?

• Original Medicare: To get preventive services with no cost-sharing, you should see a provider that accepts assignment, also known as a Medicare-participating provider. Many providers accept assignment, but you should ask your provider in advance if they accept assignment. If you see a non-participating or opt-out provider, you may be responsible for part or all of the cost of your service.
• Medicare Advantage: It is usually best to receive services from an in-network provider. Contact your provider to learn if they are in-network for your plan, or contact the plan to learn which providers are in-network. If you go out-of-network, you might be responsible for part or all of the cost of your preventive service.

What will happen during my annual wellness visit?

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider to create or update a personalized prevention plan. Medicare Part B covers the AWV if you have had Part B for over 12 months and you have not received an AWV or your Welcome to Medicare Visit in the last 12 months.

At your Annual Wellness Visit, your doctor may:

• Check your height, weight, blood pressure, and other routine measurements
• Give you a health risk assessment, which might include a questionnaire that you complete before or during the visit
• Review your functional ability and level of safety
• Learn about your medical and family history
• Make a list of your current providers, durable medical equipment (DME) suppliers, and medications
• Create a 5-10 year screening schedule or check-list
• Identify risk factors and current medical and mental health conditions along with related current or recommended treatments
• Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia
• Screen for depression
• Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing risk factors and promoting wellness

What the annual wellness is not:

• It is not a head-to-toe physical
• Although Medicare Part B covers the Annual Wellness Visit with no cost-sharing, depending on your visit, you may be responsible for paying a facility fee and/ or cost-sharing on any diagnostic services you receive

What is genetic testing fraud and abuse?

Genetic testing fraud or abuse can occur when Medicare is billed for genetic screenings or tests that are not medically necessary and were not ordered by the beneficiary’s treating physician. We often see scammers offering cheek swab tests to obtain a beneficiary’s Medicare information, which the scammers can then use for fraudulent billing or medical identity theft. Genetic testing is often advertised as one of the following:

• Cardio/cardiac genetic screening/test
• DNA screening/test
• Hereditary cancer screening/test
• Dementia screening/test
• Parkinson’s screening/test
• Pharmacogenetics (medication metabolization)

Look for these red flags to avoid genetic testing fraud and abuse:

• A company offers you “free” testing without your treating physician’s order
• A company uses “telemedicine” to offer you testing over the phone and arrange for an unrelated physician or “teledoc” to order the tests
• Medicare is billed (often thousands of dollars) for a broad range of genetic tests that you do not request or possibly even receive
• A company requests your Medicare number at a health fair, senior center, assisted living facility, mall, farmers market, or church-sponsored wellness event

To prevent genetic testing fraud and abuse, make sure to work with your trusted health care provider on your preventive health. Protect your personal information and Medicare number. Always read your Medicare statements for any suspicious charges. And finally, if you received a cheek swab or genetic screening/test that was not medically necessary, report your concerns to your local Senior Medicare Patrol (SMP).

Who to contact for more information:

• Your doctor: If you would like to schedule preventive care (such as an Annual Wellness Visit or Welcome to Medicare visit) contact your doctor or health care provider.
• State Health Insurance Assistance Program (SHIP): Contact your SHIP if you would like to learn more about how Medicare covers preventive services or if you are confused why a provider is charging you for preventive care. SHIP counselors are trained and trusted to provide unbiased Medicare counseling. In Florida the program is referred to as SHINE (Serving Health Insurance Needs of Elders). In Southwest Florida, call toll-free: 866-413-5337 or email shineinfo@aaaswfl.org.
• Senior Medicare Patrol (SMP): Contact your SMP if you believe a provider is fraudulently billing you for preventive services or if you have experienced genetic testing fraud. SMPs empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report potential health care fraud. In Southwest Florida, call toll-free: 866-413-5337 or email shineinfo@aaaswfl.org.