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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 the 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 first 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 pays 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 Don McCarty of
Financial Decision Partners, a local member of the FPA.
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