Overview

In accordance with Medicare coverage guidelines, the following preventive care services are covered through Medicare Advantage (MA) and Medicare Supplement plans:

1. Welcome to Medicare physical exam (one time only) within 12 months of the member's first coverage under Part B. Exam includes measurement of height, weight and blood pressure; an electrocardiogram; education, counseling and referral with respect to covered screening and preventive services.
2. Personalized preventive plan services; Medicare-covered annual wellness visit - available within the first 12 months of Medicare B coverage or once a year beginning 12 months after the Welcome to Medicare physical exam.
3. Cardiovascular disease screening blood tests for the early detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease), including tests for cholesterol and other lipid or triglyceride levels. There is no copayment for screening blood tests.
4. Diabetes screening tests for persons at risk of diabetes, including a fasting plasma glucose test. Individuals are considered at risk for diabetes if they have one of the following risk factors:
   1. Hypertension, dyslipidemia, obesity (body mass index (BMI) greater than or equal to 30kg/m2).
   2. Previous identification of an elevated impaired fasting glucose or glucose intolerance.
   3. Individuals who have one or more of the following risk factors:
      1. Overweight (BMI greater than 25, but less than 30kg/m2).
      2. Family history of diabetes, age 65 or older, a history of gestational diabetes mellitus or delivery of a baby weighing more than 9 pounds.
   4. Annual glaucoma screening for Medicare beneficiaries at high risk, who have a family history of the disease or who have diabetes.
5. A baseline mammogram for female Medicare beneficiaries ages 35 to 39 and an annual mammogram for female Medicare beneficiaries ages 40 and over.
6. Medical nutrition therapy by registered dietitians or other qualified nutrition professionals for Medicare beneficiaries with diabetes, chronic renal disease and post-transplant members. These benefits include:
   1. An initial assessment of nutrition and lifestyle assessment.
   2. Nutrition counseling.
   3. Information regarding managing lifestyle factors that affect diet.
   4. Follow-up visits to monitor progress in managing a diet.
7. Abdominal aortic aneurysm screening ultrasound covered one time for Medicare beneficiaries at risk through referral received from Welcome to Medicare physical exam.
8. Bone mass measurements every two years for qualified individuals considered to be at risk for osteoporosis. A qualified individual is a Medicare beneficiary who meets the medical indications for one of the following categories:
   1. An estrogen-deficient woman.
   2. An individual with vertebral abnormalities.
   3. An individual with known primary hyperparathyroidism.
   4. Some individuals receiving steroid therapy.
   5. Individuals receiving FDA-approved osteoporosis medication therapy.
   6. Procedures to identify bone mass, detect bone loss or determine bone quality, including a physician's interpretation of the results.
9. Prostate cancer screening exams for male Medicare beneficiaries ages 50 and over. These exams include a digital rectal exam and a prostate-specific antigen (PSA) test (annually).
10. Influenza and pneumococcal vaccines - Medicare members may self-refer for influenza and pneumococcal vaccines with no copayments. Providers should address the following items to help ensure compliance with this regulation:
    1. Providers should allow self-referral within the PPG.
    2. Providers unable to provide these vaccines should provide the member with a list of affiliated clinics.
11. Hepatitis B vaccine (for Medicare beneficiaries at medium to high risk for hepatitis).
12. Diabetes self-management - Provides coverage for diabetes outpatient self-management training to include services furnished in non-hospital-based programs (already covered in hospital-based programs). Physicians may provide services to others approved by the secretary of Health and Human Services (HHS) if they also provide other services paid by Medicare and meet quality standards established by the secretary. A physician managing the member's condition must certify that the services are needed under comprehensive plan care. This includes coverage for blood glucose monitors and testing strips for all diabetics (already covered for insulin-dependent diabetics).
13. Pap test and pelvic exam every two years with no copayment or deductible for women who are at low risk for cervical cancer.
14. For female Medicare beneficiaries at high risk for uterine or vaginal cancers, an annual Pap test and pelvic exam with no copayment or deductible. Barium enema for members not at high risk every four years for members ages 50 and over.
15. One annual take-home fecal-occult blood test for members ages 50 and older.
16. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse.
17. Screening for depression in adults in primary care setting.
18. Screening for sexually transmitted infections (STIs).
19. High-intensity behavioral counseling to prevent STIs.
20. Screening for obesity and counseling for eligible beneficiaries by primary care providers.
21. Multi-target stool DNA test is covered with an at-home test once every three years for people who meet all of following conditions:
    1. Between ages 50- 85.
    2. Show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test.
    3. At average risk for developing colorectal cancer, meaning:
       1. Have no personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, including Crohn's Disease and ulcerative colitis.
       2. Have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
22. Screening flexible sigmoidoscopy every four years for Medicare beneficiaries ages 50 and older not at high risk for colorectal cancer (unless a screening colonoscopy has been performed and then Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months).
23. Screening colonoscopy including anesthesia furnished in conjunction with screening colonoscopy for Medicare beneficiaries not at high risk for colorectal cancer every 10 years and every two years for members at high risk (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after 47 months).
24. Screening barium enema every four years for those not at high risk or two years for those at high risk (as an alternative to covered screening flexible sigmoidoscopy).

No office visit or facility copayment is required when only preventive services are provided to members of Medicare Advantage (MA) HMO plans and members using the in-network level of coverage for MA PPO plans.