Medicare often has been criticized for only paying for short-term illness and injury. Although this remains the general rule, there are actually quite a few “preventive medicine” services now covered by Medicare.
And now that the Affordable Care Act is on the boards, it is a fitting time to review the numerous preventive services covered by Medicare, some of which were added thanks to “Obamacare,” and all of which are now covered by Medicare and other insurances, also thanks to the ACA.
When Medicare was initiated in 1965, it specifically did not cover any kind of routine physicals or preventive screenings. But over the past 39 years, because of the evolving importance and acceptance of preventive medicine, several exceptions providing for specific preventive services were subsequently added to the covered benefits of Medicare Part B.
Recently, the ACA added an “annual wellness visit” under Medicare. Consequently, Medicare now pays for most commonly performed cancer and other screenings.
Medicare has covered cervical cancer screenings, including Pap smears and pelvic exams, since 1990, while breast cancer screenings have been covered since 1991.
Medicare has covered colorectal cancer screening since 1998. Tests may include fecal occult blood testing, screening sigmoidoscopy or colonoscopy or barium enema.
A digital rectal exam and PSA blood test to screen for prostate cancer are covered in all men ages 50 and older once every 12 months. It should be noted that American Cancer Society guidelines suggest men older than 50 should be offered prostate cancer screenings but only with a life expectancy of greater than 10 years and with an understanding of the risks and uncertainties of such testing.
In addition to cancer screenings, Medicare now covers several others, specifically for cardiovascular disease, diabetes, glaucoma and osteoporosis.
Cardiovascular disease screening refers to a cholesterol/lipid profile rather than tests for actual cardiovascular disease such as an ECG or stress test, though a screening ECG may be ordered in association with the Initial Preventive Physical Examination. Other cardiovascular tests remain noncovered for routine screening in asymptomatic patients.
Diabetes screening includes fasting or postprandial plasma glucose for any individual at risk for diabetes (including anyone older than 65). Individuals with prediabetes may be tested twice per year, and those without prediabetes may be tested once per year. Diabetic testing supplies, therapeutic shoes and inserts and insulin pumps also are covered, along with self-management training and medical nutrition therapy.
Glaucoma testing, including an eye exam and intraocular pressure measurement, is covered by Medicare once every 12 months for beneficiaries at high risk for glaucoma, people with diabetes or anyone with a history of glaucoma.
Osteoporosis screening via bone mass measurements covered by Medicare includes FDA-approved radiologic procedures to evaluate bone density in estrogen-deficient women at clinical risk for osteoporosis. Other eligible risk groups include any individual with vertebral abnormalities, receiving long-term steroid therapy or being treated and monitored with an approved osteoporosis drug.
Abdominal aortic aneurysm screening is the most recently implemented Medicare screening benefit, effective 2007. Beneficiaries must be males ages 65 to 75 and must have smoked at least 100 cigarettes or manifest other risk factors.
Medicare Part B now covers three recommended adult immunizations — influenza, pneumococcal pneumonia and hepatitis B. Any and all other federally recommended vaccinations are covered and have been under Medicare Part D since 2008. One pneumococcal vaccination for patients older than age 65 is generally considered to provide sufficient coverage for a lifetime, but Medicare also will cover a one-time booster vaccine for high-risk persons if five years have passed since their last vaccination.
Influenza vaccine is recommended in all adults 50 years and older and all health care workers. Hepatitis B vaccination is also covered by Medicare, but only for beneficiaries considered to be at high risk for the disease (those with end-stage renal disease or hemophilia, immunosuppressed patients, homosexual men and residents of institutions for the mentally handicapped). The new shingles vaccine is also recommended once for all adults older than 60.
In addition to the aforementioned specific screenings and vaccinations, Medicare Part B now covers two new types of routine exams, though these are not exactly the traditional “annual physicals” typically conducted by physicians. Other than the initial preventive physical and annual wellness visit, Medicare covers no other periodic or routine examinations.
The initial preventive physical examination (also known as the “Welcome to Medicare” exam, the IPPE) was established in 2005 subsequent to the Medicare Modernization Act of 2003. This optional exam, covered only once per beneficiary per lifetime, must be performed during the first 12 months (formerly six months) of Medicare Part B coverage (i.e., usually at 65-66 years old).
This exam includes several mandatory elements: a comprehensive medical and social history, review of risk factors for depression, functional and safety assessment, a focused physical exam including height, weight, blood pressure and visual acuity and education and counseling regarding any issues identified in the previous elements and regarding other available preventive services under Medicare. The IPPE may be performed by a physician or qualified physician assistant, nurse practitioner or clinical nurse specialist.
The annual wellness visit is another new type of routine/annual examination established by Obamacare. This optional visit may be performed one year after the IPPE and then annually. Rather than a routine physical it is really a compilation of geriatric and risk factor assessments, culminating in personalized prevention plan services.
The following components must be included: updated medical and family history; list of current providers and suppliers of medical care and equipment; height, weight, blood pressure and other measurements as deemed appropriate; and detection of cognitive impairment and depression and review of functional ability and level of safety.
A list of risk factors and scheduled preventive services and referrals should then be produced for the patient.
In conclusion, Medicare has appropriately evolved with modern medical practice to include most commonly recommended preventive screenings and vaccinations. Of course, virtually any test or examination may be done and billed to Medicare when medically necessary and accompanied by a relevant diagnosis. However, routine physicals or any routine or screening tests other than those specifically discussed above are not covered by Medicare.
Clinicians and patients should take advantage of these new and evolving Medicare-covered benefits to foster preventive health at any age.
Dr. Todd Goldberg, a nationally prominent board-certified geriatrician, is associate professor of medicine and director of the Geriatrics Program at WVU Charleston (W. Va.) and Charleston Area Medical Center. He formerly was medical director of Pauls Run, the continuous care retirement community in Northeast Philadelphia. This article originally appeared in The Good Life, a Jewish Exponent supplement.