Medicare Preventive Services Module 7

Session Topics  What is covered – Why preventive services are important – Who is eligible – How much you pay  Information sources Medicare Preventive Services207/12/2010

3 Living a Healthy Lifestyle  Eat well  Exercise  Keep a healthy weight  Don’t smoke  Get preventive services to – Delay or lessen the effects of diseases – Find disease early – Get shots to keep you from getting dangerous infections Medicare Preventive Services07/12/2010

4 Medicare Preventive Services  Medicare coverage based on – Age – Gender – Medical history  Covered by – Part B of Original Medicare – Medicare Advantage and other Medicare plans Medicare Preventive Services07/12/2010

5 Covered Screening and Preventive Services  One time “Welcome to Medicare” physical exam  Physical Exam (yearly “Wellness Exam”) Starts 2011  Abdominal aortic aneurysm screening*  Bone mass measurement  Cardiovascular disease screenings  Colorectal cancer screenings  Diabetes screenings  EKG Screening*  Flu shots  Glaucoma tests  Hepatitis B shots  HIV Screening  Mammograms (screening)  Pap test/pelvic exam/clinical breast exam  Prostate cancer screening  Pneumococcal shots  Smoking cessation Medicare Preventive Services Health Reform Section 4103 *When referred during Welcome to Medicare physical exam 07/12/2010

6 What You Pay in 2010  Original Medicare – Generally 20% after Part B deductible Medigap or other policies may pay the 20% May have to pay more if o Provider does not participate in Medicare o Provider does not accept assignment Some services cost less  Medicare Advantage or other Medicare plan – May have copayment Medicare Preventive Services07/12/2010

7 Elimination of Part B Deductible and Coinsurance Requirements in 2011  Starting January 1, 2011  You pay nothing for most preventive services – If you get them from a doctor or other health care provider who accepts assignment  Services affected must have an “A” or “B” rating – By the United States Preventive Services Task Force Medicare Preventive Services Health Reform Section /12/2010

8 One Time “Welcome to Medicare” Physical Exam  Covered within first 12 months of having Part B – Height, weight and body mass index – Blood pressure and end of life planning – Education, counseling, and referrals (e.g., EKG)  In Original Medicare you pay – 20% of the Medicare-approved amount –No deductible –Effective January 1, 2011, you pay no copayment if doctor accepts assignment Medicare Preventive Services Changes in /12/2010

9 Abdominal Aortic Aneurysm Screening  Abdominal aortic aneurysms (weak area bulges)  Risk factors include – A family history of abdominal aortic aneurysms – Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime  Ultrasound screening covered by Medicare – Referral from the “Welcome to Medicare” physical exam – You pay 20% of the Medicare-approved amount with no Part B deductible – No deductible or copayment starting January 1, 2011 Medicare Preventive Services Changes in /12/2010

10 New Annual Wellness Visit  Effective January 1, 2011  Annual Wellness Visit – Comprehensive health risk assessment – Personalized prevention plan – Health advice and referral to education and preventive counseling – No copayment or deductible – Available every 12 months (after first 12 months of initial Part B coverage) o But not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness visit Medicare Preventive Services Health Reform Section /12/2010

11 Bone Mass Measurement  Covered if at risk for osteoporosis –Every 2 years (more often if medically necessary)  Risk factors include but aren’t limited to –Age 50 or older –Female –Family or personal history of broken bones –White or Asian  In Original Medicare you pay –20% after Part B deductible –No deductible or copayment starting January 1, 2011 Medicare Preventive Services Changes in /12/2010

12 Cardiovascular Disease Screening  Blood test for early detection – Heart disease – Stroke  Tests for levels of – Cholesterol – Triglycerides – Lipids  Covered every 5 years  In Original Medicare you pay nothing Medicare Preventive Services07/12/2010

Cardiac Rehabilitation  Medicare covers cardiac programs that include – Exercise – Education – Counseling certain patients with a doctor’s referral – Intensive cardiac rehabilitation programs  You pay 20% of the Medicare-approved amount – If you get the services in a doctor’s office No change in 2011  You pay a copayment In a hospital outpatient setting Medicare Preventive Services1307/12/2010

14 Colorectal Cancer Screening  Helps find precancerous growths – Helps prevent or find cancer early  One or more of the following tests may be covered – Fecal Occult Blood Test – Flexible Sigmoidoscopy – Colonoscopy – Barium Enema Medicare Preventive Services07/12/2010

15Medicare Preventive Services Colorectal Cancer Screening (continued) Test and Requirements Covered Once Every… You Pay Fecal Occult Blood Test Age 50 or older 12 monthsNo cost for the test. Generally pay 20% of the Medicare-approved amount for the doctor’s visit. No deductible or copayment starting January 1, Flexible Sigmoidoscopy Age 50 or older 48 months or 120 months after a previous screening colonoscopy for those not at high risk Doctor’s service –generally 20% of the Medicare-approved amount Hospital outpatient setting - you pay a copayment. No deductible or copayment starting January 1, Colonoscopy No minimum age 120 months (generally) (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy 20% of the Medicare-approved amount for doctor’s services A copayment in a hospital outpatient setting. No deductible or copayment starting January 1, Barium Enema Age 50 or older 48 months (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy You pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. No change in Changes in /12/2010

16 Diabetes Risk Factors  Diabetes is a chronic condition – Body does not produce or properly use insulin  Risk Factors – High blood pressure – High cholesterol – Obesity – History of high blood sugar – At least two of the following Age 65 or older, overweight, family history of diabetes, or past gestational diabetes or having a baby over 9 pounds Medicare Preventive Services07/12/2010

17 Diabetes Management  May be able to avoid or delay complications  You can manage your diabetes – Test blood sugar regularly – Eat a proper diet – Exercise regularly – Take medication as prescribed Medicare Preventive Services07/12/2010

18 Diabetes Screening  Testing for people at risk  Includes fasting blood glucose test  Talk with your doctor about frequency – Up to twice in a 12-month period  Original Medicare – No deductible or coinsurance Medicare Preventive Services07/12/2010

19 Covered Diabetes Services  Screening for all at risk  For people with diabetes – Self-management training – Medical nutrition therapy – Blood sugar testing supplies Insulin and related supplies – Special eye exams – Hemoglobin A1c tests Medicare Preventive Services07/12/2010

20 Covered Diabetes Services  People with diabetes who need them – Insulin pumps – Special foot care – Therapeutic shoes  In Original Medicare you pay – 20% after Part B deductible – No change in 2011  Medicare Coverage of Diabetes Supplies & Services (CMS Pub ) Medicare Preventive Services07/12/2010

21 Glaucoma Examination  Glaucoma is caused by increased eye pressure – May gradually lose sight without symptoms  Protect yourself with screening eye exam  Covered if high risk once every 12 months  In Original Medicare you pay – 20% of the Medicare-approved amount Part B deductible applies for the doctor services – A copayment in a hospital outpatient setting – No change in 2011 Medicare Preventive Services07/12/2010

HIV Screening  Medicare covers HIV screening for people – Who are pregnant or at increased risk for the infection – Includes anyone who asks for the test  Covered once every 12 months – Up to 3 times during a pregnancy  No cost for the test – Generally you pay 20% of the Medicare-approved amount for the doctor’s visit – No deductible or copayment for the test – No change in 2011 Medicare Preventive Services2207/12/2010

23 Pap Test and Pelvic Exam with Clinical Breast Exam  Risk factors for some cancers in woman include but aren’t limited to – Abnormal Pap test – Human papilloma virus (HPV)  Medicare covers – Pap test to help find cervical and vaginal cancer – Screening pelvic exam to help find fibroids/ovarian cancers – Clinical breast exam (another way to look for breast cancer) Medicare Preventive Services07/12/2010

24 Pap Test and Pelvic Exam with Clinical Breast Exam  Covered for all women with Medicare – Once every 24 months – Once every 12 months if At high risk for cervical or vaginal cancer Childbearing age and abnormal Pap test in the past 36 months Medicare Preventive Services07/12/2010

25 Pap Test and Pelvic Exam with Clinical Breast Exam  In Original Medicare you pay – Nothing for Pap lab test – 20% for Pap test collection, pelvic exam, and clinical breast exam – No Part B deductible – No copayment starting January 1, 2011 Medicare Preventive Services Changes in 2011 Health Reform Section /12/2010

26 Prostate Cancer Risks  Risk increases with age – Age 45 – 1 in 2,500 – Age 50 – 1 in 476 – Age 55 – 1 in 120 – Age 60 – 1 in 43 – Age 65 – 1 in 21 – Age 70 – 1 in 13 – Age 75 – 1 in 9  Ethnicity risk  Hereditary risk Medicare Preventive Services07/12/2010

27 Prostate Cancer Screening  Covered – For all men with Medicare – Beginning the day after 50th birthday  Tests include – Digital rectal exam – PSA blood test Prostate-specific antigen  In Original Medicare you pay – Nothing for the PSA blood (lab) test – 20% after Part B deductible for digital rectal exam No change in 2011 Medicare Preventive Services07/12/2010

28 Breast Cancer and Mammography  Breast cancer in women in U.S. – Most commonly diagnosed non-skin cancer – Second leading cause of cancer death – Risk increases with age – Successfully treated when found early  Mammogram – Checks for abnormal breast tissue – Coverage includes digital technology Medicare Preventive Services07/12/2010

29 Screening Mammogram  Covered for all women with Medicare – One baseline mammogram age 35 to 39 – Once a year starting at age 40  In Original Medicare you pay – 20% coinsurance – No Part B deductible – No deductible or copayment starting January 1, 2011 Medicare Preventive Services Changes in 2011 Health Reform Section /12/2010

30 Diagnostic Mammogram  Used when there are clinical findings – On physical exam – Abnormal screening mammogram  Medicare covers as many as needed – Also covered for men  Different payment rates if diagnostic mammogram Medicare Preventive Services07/12/2010

31 Smoking Cessation  Quitting gives significant health benefits – Even older adults who smoked for years  When services are covered – If you have an illness caused/complicated by tobacco use – If you take medication affected by tobacco use Medicare Preventive Services07/12/2010

32 Smoking Cessation Services  Cessation counseling – Up to 8 sessions per year – Inpatient or outpatient – Intermediate or intensive  In Original Medicare you pay – 20% after Part B deductible No change in 2011  Medicare Part D prescription drug coverage – Can help pay for drug therapy Nicotine patches, for example Medicare Preventive Services07/12/2010

33 Influenza (“Flu”) Shot  Flu can lead to pneumonia – Can be dangerous for people 50 and over  Flu viruses are always changing – Shot updated for most current flu viruses  Flu shot covered for all people with Medicare  Once each flu season protects for about a year  In Original Medicare you pay – No deductible or copayment Medicare Preventive Services07/12/2010

H1N1 Flu Vaccine  H1N1 flu is caused by a new strain of influenza virus  Risk factors not as high for those over 65 – Higher risk for those with certain disabilities  Medicare covers administration of the H1N1 flu shot – You can’t be charged for the vaccine (providers get it free) – You pay nothing if provider accepts assignment – Part B deductible and coinsurance don’t apply To the vaccine or its administration  You should still get the seasonal flu shot Medicare Preventive Services3407/12/2010

35 Pneumococcal Pneumonia Shot  Pneumonia is inflammation in the lungs – Caused by bacteria (streptococcus pneumoniae)  One shot could be all you ever need  All people with Medicare are eligible  In Original Medicare you pay – No deductible or copayment Medicare Preventive Services07/12/2010

36 Hepatitis B Shots  Serious disease (virus attacks the liver) – Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, or death  Covered for medium to high risk – End-stage renal disease and hemophilia – Condition that lowers resistance to infection  In Original Medicare you pay – 20% after Part B deductible – No deductible or copayment starting January 1, 2011 Medicare Preventive Services Health Reform Section 4104 Changes in /12/2010

Medicare Education Benefit  People with Stage IV chronic kidney disease – Have advanced kidney damage and – Will likely need dialysis or a kidney transplant soon  Medicare Part B covers – Up to six sessions of kidney disease education services if your doctor refers you for the service  Provided to help prevent or delay the need for dialysis – You pay 20% of the Medicare-approved amount, and the Part B deductible applies No change in 2011 Medicare Preventive Services3707/12/2010

38 Exercise A. Your risk for osteoporosis is higher if you 1.Are a man 2.Are African-American 3.Have a low-calcium diet 4.Are overweight Medicare Preventive Services07/12/2010

39 Exercise B. Medicare provides annual coverage for glaucoma screening for people with Medicare in the following high-risk categories 1.Individuals who have diabetes 2.Individuals who have a family history of glaucoma 3.African-Americans age 50 and over 4.Hispanics age 65 and older 5.All of the above Medicare Preventive Services07/12/2010

40 Exercise C. The best time to get a flu shot is in January or February 1.True 2.False Medicare Preventive Services07/12/2010

41 If You Want to Know More…  Centers for Medicare & Medicaid Services – Medicare Preventive Services, Pub – Medicare & You handbook, Pub – Your Medicare Benefits, Pub – MEDICARE ( ) TTY – Medicare Preventive Services07/12/2010

42 If You Want to Know More…  Local State Health Insurance Assistance Program (SHIP) – Phone number in Medicare & You handbook  American Cancer Society – – ACS-2345 Medicare Preventive Services07/12/2010

43 If You Want to Know More…  Cancer Information Service – Live Help link at – CANCER (TTY users call )  Centers for Disease Control and Prevention –  HHS tobacco cessation resources – Medicare Preventive Services07/12/2010

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