Does Medicare Cover Preventative Services?
Yes, Medicare Part B covers many preventative services with no deductible or coinsurance. Preventative services detect or even prevent health problems through testing, vaccines, counseling, and education.
These approaches help prevent more significant health issues from becoming serious diseases and can even save lives. This is in contrast to diagnostic care, where you visit a doctor because you have symptoms or were already diagnosed with a condition.
Preventive services covered by Medicare include the following and more:
- One “Welcome to Medicare” preventative visit
- Annual wellness visits
- Screenings for cardiovascular disease, diabetes, cancer, and other serious diseases
- Counseling and interventions for risky behaviors or conditions
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Getting Ahead of Your Health With Medicare
Preventive care encourages a patient and physician to be proactive instead of reactive. Doing so allows you to identify potential issues early, live longer, and feel healthier. With the correct information and approach, you can prevent the potential problem from becoming a serious (and expensive) ongoing health condition that Medicare may or may not fully cover.
Older adults are at a higher risk of the following:
- Alzheimer’s disease
- Injuries due to falls
- Pneumonia and other infectious diseases
For example, suppose you’re at your annual wellness visit, and your doctor orders a blood glucose test to screen for diabetes. Your test results indicate you’re prediabetic. Modifying your diet or exercise regimen could reduce your blood sugar again and prevent future health issues.
Now imagine that without preventive tests and counseling, you do not notice diabetes until symptoms develop. You’ll need to manage your condition with medications and are at higher risk for additional health issues.
How Does Medicare Cover Preventative Services?
Medicare covers preventative services in various ways:
- Medicare Original Part B: Part B covers physician visits and some vaccines
- Medicare Part C or Medicare Advantage: Covers everything that Part B does and may also cover additional preventative services not covered by Original Medicare
- Medicare drug plan (Part D): Your prescription drug plan will cover most vaccinations not covered by Part A or B, such as the shingles vaccine
- Medigap: Can help pay for some Medicare coverage costs
- Medicaid: A state-based aid program for low-income people that can help pay for Medicare’s costs
Eligibility for Preventative Services
In order to receive Medicare coverage for preventive services, you must first be eligible for Medicare, meaning you’re 65 and older or eligible because of a certain disability or disease.
Some preventive services may only be available every few years or only to specific at-risk populations. For example, if you’re a male who’s smoked over 100 cigarettes, you may qualify for an abdominal aortic aneurism (AAA) screening ultrasound. If you’ve never smoked, you will not need the screening and will not be eligible for coverage unless you have a family history of AAA.
What Preventative Services Does Medicare Cover?
Preventative services covered by Medicare include a wide array of screening services if indicated, four types of vaccinations, and counseling services for some chronic conditions.
When you enroll in Medicare Part B, you’ll get a “Welcome to Medicare” or Initial Preventive Physical Exam (IPPE) visit in the first 12 months. With your physician, you’ll:
- Discuss your family, medical, and social history
- Learn about preventive services
- Review your medical records and immunization records
- Talk about your over-the-counter and prescription drugs, vitamins, and supplements
The doctor will also measure your height, weight, and blood pressure, perform a simple vision test, and calculate your body mass index (BMI). Some screenings may be performed, including depression risk. Flu and pneumococcal shots are offered, along with a plan for needed shots, screenings, or additional preventive services.
A year later, you’re eligible for your annual wellness visit or your plan to avoid developing diseases and disabilities. You’ll fill out a “Health Risk Assessment” questionnaire. Based on your answers or other risk factors, the doctor may review your medical and family history and your current prescriptions.
Routine measurements such as height, weight, and blood pressure may be taken, along with an assessment for signs of dementia. The doctor will then offer personalized health advice and discuss planning for your care if you cannot speak for yourself.
However, neither the initial preventive physical exam nor the wellness visit is a full, routine physical exam. They may have similar elements or components, such as noting your height and weight. For your routine physical, you must pay 100% out of pocket.
Screening looks for potential health disorders or diseases, even if you do not yet have symptoms. Screenings look for physical and mental health issues before they become serious problems. Medicare-covered screening services include:
- Abdominal aortic screening with an ultrasound if you’re at risk
- Alcohol misuse screening if you are not dependent
- Cardiovascular disease screenings with a blood test
- Well-woman screenings
- Colorectal cancer screenings, whether through DNA tests, colonoscopies, blood tests, or other forms
- Depression screenings
- Diabetes screenings
- Glaucoma tests, if at high risk of developing the eye disease
- Hepatitis B and C and HIV infection screenings
- Lung cancer screenings
- Obesity screenings if you have a body mass index (BMI) of 30 or more
- Prostate cancer screenings with physical exams and blood tests
- Sexually transmitted infections (STI) screenings
It’s worth noting that some covered screenings have their own eligibility requirements, so speak to your doctor if you have questions.
Vaccinations help prevent disease and are an integral part of preventative healthcare. You may be able to get vaccines at your doctor’s office or even your local pharmacy. The different types of vaccinations Medicare covers include:
- Flu shots
- Hepatitis B shots if you’re at medium or high risk for Hepatitis B
- Pneumococcal shots
- COVID-19 vaccines
Medicare Part B covers most necessary vaccines but not all. Your Medicare drug plan can often fill in the gaps, offering coverage for other vaccines, such as the shingles shot.
The counseling services offered by Medicare are not traditional mental health counseling services. Instead, they’re interventions designed to help you prevent disease:
- Alcohol misuse counseling: 4 brief face-to-face counseling sessions each year if your alcohol misuse screening indicates the need
- Diabetes self-management training: Up to 10 hours of individual and group training
- Medicare Diabetes Prevention Program: 6 months of weekly group sessions focused on lasting diet and exercise changes
- Nutrition therapy services: Those with diabetes or kidney disease or a kidney transplant receive nutrition and lifestyle assessment and benefits from a registered dietician
- Obesity counseling: Dietary assessment and counseling focused on diet and exercise to help with weight loss
- Sexually transmitted infections counseling: Face-to-face, high-intensity behavioral counseling sessions if your screening indicates need
- Tobacco use cessation counseling: Up to 8 sessions in 12 months to help you quit tobacco
What Preventative Services Are Not Covered?
Non-covered services include the following:
- Services deemed not medically reasonable and necessary: For example, preventive screenings more often than Medicare allows are not covered.
- Preventive services outside the U.S.: Original Medicare only covers U.S.-based procedures.
- Vaccines beyond the few Part B immunizations: You’ll need Part D coverage for additional vaccines.
- Preventative services performed by non-approved providers: For example, your services may not be covered if a chiropractor or concierge medicine doctor carries out your annual wellness visit.
Other specific exclusions include:
- Routine physical checkups
- Eye exams for eyeglasses or contact lenses
- Hearing exams for hearing aids
- Cosmetic surgery
- Dental exams and services
Does Medicare Advantage Cover Preventative Services?
Medicare Advantage covers the same preventative services as Original Medicare. For example, Original Medicare and Medicare Advantage cover the Medicare Diabetes Prevention Program. You can also still get the “Welcome to Medicare” exam.
Some Medicare Advantage programs also offer extra preventive services, including an annual preventive physical exam or vision, dental, and hearing screenings. Some plans also offer fitness or gym memberships, which can boost physical fitness, preventing falls and chronic illness.
How Much Do Preventative Services Cost with Medicare?
Many preventive services are free with Medicare coverage. But that does not mean you pay nothing for the year of coverage. Preventative service costs depend on several factors:
- Premiums: You must have Part B to qualify for most of Medicare’s preventive offerings. Original Medicare Part B premiums are at least $164.90/month. For Part D coverage for other preventive immunizations, costs vary by plan.
- Deductible: With Original Medicare, your deductible is $226 per year. You pay this before Medicare starts paying your costs. Part D deductibles vary by plan.
- Copays or coinsurance: Your portion of a preventive visit or service cost. Part B coinsurance may depend upon the service provided. Part D deductibles vary by plan and pharmacy.
Additional out-of-pocket costs: You might need to pay coinsurance, Part B deductible costs, or the full amount if your doctor performs non-covered tests or services or recommends you get services more often than Medicare covers.
Financial Assistance From Medigap
Private companies sell Medigap, which helps pay for your deductibles (except Part B in some cases), coinsurance, and copays and can limit the amount you pay out of pocket. You pay an additional premium to the company for your Medigap plan. Still, in exchange, you get a dependable source of financial assistance and can even buy a plan that covers international travel.
However, you’ll still face some challenges — Medigap plans do not cover vision or dental services, for example. Some Medigap plans only pay part of your coinsurance or copayment.
You may also be able to get extra financial assistance from your state’s Medicaid office, specifically with help paying for Medicare premiums, drug costs, and more.
How To Access Coverage For Preventative Services
- Register at MyMedicare.gov. You’ll have a personalized account of preventive services, create a list of your prescriptions, a 2-year calendar of eligible Medicare-covered tests and screenings, and a customized report to bring to your next doctor’s appointment.
- Ensure your doctor accepts assignment. This means the provider accepts Medicare as full payment for your preventative service. For Medicare Advantage, your doctor will likely need to be in the plan’s network.
- Ask about any out-of-pocket costs. Either speak with the billing department or your Medicare Advantage plan administrator and ask if your upcoming preventive test, item, or service is covered and if there are ways to avoid out-of-pocket costs.
- Schedule your appointment. If your doctor suggests any new tests, screenings, or procedures at the appointment, ask if Medicare covers them. However, be mindful that your doctor or health care provider may recommend preventive services or screenings that are not covered but are still necessary.
All in All
Preventive services, such as screenings, vaccinations, and education, are among the most critical steps you can take for continued good health as you age. Medicare makes many of these services low-cost or free and helps tailor preventive services to your risk profile.
Ensure you understand what preventive services are covered and what is not before you make an appointment or get the bill. You might have access to more preventive services with some Medicare Advantage plans.
Make sure to take advantage of preventive visits — and accompanying screenings and immunizations — to improve or even boost your health. Doing so will prevent chronic disease through early detection and appropriate management, such as lifestyle, diet, and physical exercise changes.