Medicare preventive services usually come at no cost. But, in some cases, you’ll pay a portion. Medicare encourages patients to use appropriate screenings to their advantage. It’s cheaper to prevent disease than it is to treat disease. You can be proactive by scheduling an appointment to prevent disease. It’s easier to stay healthy than to become healthy. Below we’ll discuss the frequency and coverage for Medicare preventative services.
Your Guide to Medicare Preventive Services
Medicare preventive services include lab tests, exams, screenings, and shots. Health monitoring programs, training, and counseling also have coverage. Your doctor reviews services during the “Welcome to Medicare” and Annual Wellness Visits. The Medicare preventative service checklist helps you track the services you complete and the tests you need.
If services are inpatient, they fall under Part A. But, outpatient services fall under Part B. While most preventive services are available at no cost to you, treatment isn’t.
Below we explain the differences between several types of appointments as well as the preventive services you may need.
Medicare Preventative Visit vs. Welcome to Medicare
The Medicare preventative visit and the welcome to Medicare visit aren’t the same things. But, they do hold some similarities. preventative care can include tests a doctor suggests after a welcome to Medicare visit. Also, preventive care can be screening recommendations after an Annual Wellness Visit.
Most preventive services don’t cost you anything. Also, the welcome to Medicare visit won’t cost you. But, your doctor may request further testing that has costs.
Use this visit as a way to get valuable information on screenings and shots. It’s been a great time to talk with your doctor about your family history and discuss ways to stay healthy.
During this visit, your doctor will:
- Give you a simple vision test
- Check your height, weight, and blood pressure
- Calculate your body mass index (BMI)
- Record your medical and social history (like alcohol or tobacco use, your diet, and your activity level)
- Review your potential risk for depression and your level of safety
- Talk with you about creating advance directives
Advance directives are legal documents that allow you to put in writing what kind of health care you would want if you were too ill to speak for yourself
You can expect your doctor to give you advice and counseling to help you prevent disease, improve your overall health, and discuss a way to stay well.
When you go to the “Welcome to Medicare” preventive visit, bring these items:
- Your medical records, including immunization records
- Your family health history
- A list of prescription and over-the-counter drugs that you currently take
This visit is only covered one time, and the appointment must take place within the first 12 months you’re enrolled in Part B.
Medicare Preventive Care vs. Wellness Visit
Preventative services seem similar to the Annual Wellness Visits. Both have a goal to keep you healthy, but they aren’t the same. Medicare preventive services include vaccines and screenings. Also, these services help you avoid disease or catch health issues early.
Preventative services consist of screenings and vaccines. The Annual Wellness Visit is your yearly check-in to discuss your health and wellness.
If you had Part B for more than 12 months, you could get a yearly “Wellness” visit to develop a disease prevention plan.
The Annual Wellness Visit includes:
- Health risk assessment
- Height, weight, blood pressure, and other routine measurements
- Develop or update a list of current providers and prescriptions
- Review of medical and family history
- Detection of any cognitive impairment
- Personalized health advice
- A list of risk factors and treatment options for you
- A checklist for preventive services
You don’t need to have had a “Welcome to Medicare” preventive visit before getting a yearly “Wellness” visit. At the Annual Wellness Visit, you’ll likely make an appointment for further preventative care.
Medicare Preventive Service Visit vs. Routine Physical
The preventive exam doesn’t include physical tests such as lung exams and reflexes. But, if there is a symptom that necessitates that kind of screening, Medicare will cover it. Medicare doesn’t cover routine physicals. You’ll pay 100% of the costs for a routine physical.
The average cost of a routine physical without insurance ranges from $50- $200, although the costs could be more.
Medicare’s Preventative Care Service Checklist
Every five years, Medicare covers cardiovascular screening blood tests. The blood tests help detect conditions that would lead to a stroke or heart attack.
During your cardiovascular screening, your doctor might:
- Check for high blood pressure
- Offer counseling to help create a healthy diet
- Advice on the benefits of the use of aspirin if you’re in a particular age range
Part B benefits will cover cardiovascular disease risk screening annually. Medicare covers the full cost if it’s with a participating provider.
Cardiovascular Behavioral Therapy
Part B covers cardiovascular behavior therapy. Cardiovascular behavior therapy can help lower the risk of cardiovascular disease. The doctor will discuss aspirin use, check blood pressure, and give healthy eating tips. Medicare will cover this visit once per year at the primary care doctor’s office.
You don’t pay anything for the visit when the doctor accepts Medicare assignment.
Abdominal Aortic Aneurysm Screening
Medicare covers a one-time abdominal aortic aneurysm ultrasound for people at risk. You’re at risk for abdominal aortic aneurysms if they run in your family. Also, if you’re a man, ages 65 to 75, and have smoked at least 100 cigarettes in your life.
If the doctor accepts Medicare assignment, you pay nothing for this screening. But, you must get a referral from your doctor.
Should you need a second ultrasound, Medicare may deny coverage, and you may be responsible for the entire cost of the scan.
If the doctor discovers a health issue that requires additional care, you could be responsible for costs relating to that condition.
EKG or ECG Screenings
Part B covers an electrocardiogram screening when you have a referral from a doctor as part of your one-time “Welcome to Medicare” visit. EKGs also have coverage as diagnostic tests. Both screenings have coverage when they’re part of the “Welcome to Medicare” visit, beyond that they’re diagnostic tests.
When using a doctor that accepts Medicare, you’ll pay 20% of the costs after you meet the Part B deductible.
Obesity Screening and Counseling
Body Mass Index screenings can help you lose weight if your BMI is high. Part B covers both Body Mass Index screens and counseling to help you lose weight if you’re obese. What constitutes obesity? Well, if you have a BMI of 30 or more. When your doctor determines that you’re overweight, you’ll qualify for therapy to help lead you to a better diet and proper exercise.
Medicare will cover a range of appointments for behavioral counseling:
- One in-person visit once a week for your first month
- One in-person visit every other week between months 2-6
- Also, one in-person visit each month between months 7-12 – This is conditional on if you can lose up to 6.6 lbs within the first six months
After your initial six months of treatment, you’ll go through another screening for obesity. During this, your physician will decide how much weight you’ve lost following your first screen.
To qualify for further in-person appointments with your physician throughout months 7-12 of therapy, you’ll need to lose a minimum of 6.6 lbs during your first six months of treatment.
If you don’t lose at least 6.6 pounds in the first six months of your visits, your therapy could end. Your doctor can check you for another obesity test after another six months passes.
Beneficiaries have 100% coverage through Medicare.
Medicare covers diabetic screenings when you’re at risk for the disease. The testing could incorporate a fasting blood glucose test and a post-glucose test.
Depending on your risk, Medicare may cover these tests twice for the year.
Medicare cover diabetic screenings if you have any of these risk factors:
- High Blood Pressure
- Dislipidemia (History of abnormal cholesterol levels)
- High Blood Sugar
- Impaired glucose tolerance
Further, you may qualify if you relate to two of the following:
- You’re overweight
- Have a family history of diabetes
- Family history of gestational diabetes or large babies at birth
You don’t pay anything for preventative screenings. But, further testing or visits could cost 20% of the bill after applicable deductibles are met.
Diabetes Self-Management Training
Self-management training can help you stay active, eat better, monitor blood sugar levels, and maintain overall health. Medicare benefits will cover 10 hours of self-management training in your first year. One hour is individual training, and the other 9 hours you’ll complete in group training. You’ll need a referral to qualify. Those in rural areas could be eligible for diabetes self-management training via telehealth visit from a doctor or Registered Dietician
Following your first year, Medicare covers two hours of training each subsequent year. Medicare covers 80% of the cost for your diabetes self-training.
Blood Sugar Monitors
Part B covers blood sugar monitors as Durable Medical Equipment with a doctor’s prescription. You must use a doctor and supplier that accept Medicare. You’ll pay 20% of the costs after the deductible. When you use a doctor or supplier that isn’t enrolled in Medicare, you will pay the full cost. When suppliers don’t accept assignment, there’s no limit to the amount they can charge you.
Blood Sugar Test Strips
The same way glucose monitors are Part B Durable Medical Equipment, the blood sugar test strips fall into the same category. You’ll pay 20% of the costs if you don’t have Medigap coverage. Those with a Medicare Advantage plan could pay a different amount. Each Advantage plan is different, consult your policy about your coverage.
You must always use a doctor AND supplier that participate in Medicare.
Kidney Disease Education
Part B covers up to 6 sessions of kidney disease education if you have Stage IV Chronic Kidney Disease that will require dialysis or kidney transplant. The deductible applies, and then you pay 20% of the costs. Kidney Disease Education can teach you how to care for your kidneys and give you information about managing health conditions. The training goes over what you should and shouldn’t eat.
Further, they discuss the treatment options if your kidneys get worse. There will even be discussions about how you’ll feel, your family life, social life, work, finances, and mental health. Also, you’ll learn about how your kidneys work, how the medications work, and your rights for treatment.
Medical Nutrition Therapy Services
Provided your doctor refers you for this service, you pay nothing. Nutrition professionals and registered dieticians can provide these services. Medical Nutrition Therapy Services include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.
People with these conditions have coverage:
- Renal disease (people who have kidney disease, but aren’t on dialysis)
- A kidney transplant within the last three years. Your doctor does need to refer you to this service.
Medicare covers 3 hours of one-on-one counseling the first year, and 2 hours each year after that. If the condition, treatment, or diagnosis changes, you may be eligible for more hours with a doctor’s referral.
A doctor must prescribe these services and renew your referral yearly if continuing treatment rolls into another calendar year.
Medicare will cover a glaucoma test every year if you’re high-risk. You pay 20% of the cost after meeting the Part B deductible.
You’re high risk for glaucoma if:
- You have diabetes
- Family history of glaucoma
- African American 50 years or older
- Hispanic 65 years or older
An eye doctor in your approved to test in your state must do or supervise the screening. Medicare may cover certain eye services if you have a chronic eye condition such as cataracts or glaucoma.
Coverage includes surgery to remove a cataract and replace your lens with a fabricated intraocular lens. Medicare covers one pair of eyeglasses or contacts after cataract surgery.
Medicare covers eye exams that test for potential vision problems that would indicate a severe condition.
Macular Degeneration Screening
Since the Macular Degeneration Screening is diagnostic, you’ll pay 20% of the Medicare amount for the drug and the doctor’s services. Also, the Part B deductible is applicable. Further, Medicare Part B doesn’t cover routine vision, but it’ll cover treatment for age-related macular degeneration.
Bone Mass Measurements
Bone mass measurements help determine the need for treatments for osteoporosis. Part B covers bone mass measurements if you’re at risk for osteoporosis every two years.
You’re eligible for bone mass measurement if:
- You’re a woman who is lacking estrogen
- You had steroid treatments every day for more than three consecutive months
- There are abnormalities to your vertebrae shown via x-rays
- You have osteoporosis drug therapy
- A doctor diagnoses you with hyperparathyroidism
You must obtain a referral. When eligible for the bone density test, coverage is 100%. The test helps see if you’re at risk for broken bones.
Should you need follow-up appointments for re-measurement or screenings, Medicare covers these.
Alcohol Misuse Screening and Counseling
Part B covers one alcohol misuse screening per year. If a doctor confirms you’re misusing alcohol, you’ll qualify for four face to face counseling sessions annually.
Possible symptoms of misusing alcoholic beverages can include:
- Anyone who’s under the age of 65 and has more than three drinks when they drink or seven drinks each week
- Women who are under 65 years old and drink three or more alcoholic beverages in a sitting or at least seven alcoholic drinks a week
- Men under the age of 65 who have more than four beverages at once or 14 drinks per week
You must be alert and competent while counseling takes place. There are no costs if the doctor accepts Medicare.
Care must take place in a doctor’s office. A doctor would deem treatment necessary when you drink three or more beverages at a time or seven drinks weekly.
Medicare doesn’t cover alcohol misuse screening in a hospital stay or emergency room visit. It’s important to talk with your doctor about any substance abuse issues.
Depression Screening Covered Under Medicare
Part B covers one depression screening annually. You must use a doctor that accepts Medicare, and it must be in the doctor’s office. Medicare won’t cover a screening in an emergency room or hospital. If the doctor believes you’re at risk for depression, you will have a referral to a mental health specialist.
The doctor must review your potential for depression during your Welcome to Medicare or Annual Wellness Visit. But, the doctor doesn’t need to screen you for depression during the visit formally.
Usually, the doctor will include it in a scheduled visit. But, the doctor can choose to screen you at a separate appointment.
Mental health is just as important as physical health; Medicare covers 100% of the cost of your screening. But, if the doctor determines you need diagnostic care, there will be costs.
Then, if you need medications, depression is part of the six protected classes.
Sexually Transmitted Infections Screening and Counseling
Medicare covers Sexually Transmitted Infection screenings once a year if you get a referral from your doctor. Your doctor can determine if you’re at high-risk for STIs while at your appointment.
Part B will cover screening for gonorrhea, chlamydia, syphilis, and hepatitis B if you’re:
- At high-risk
Medicare will cover screenings for gonorrhea and chlamydia:
- Once a year, if you’re a woman with risk
- You’re pregnant and younger than 24
- If you’re pregnant and are at high-risk
Medicare will cover syphilis tests:
- Once a year, if at risk
- If you’re pregnant
Medicare covers STI screenings at 100%. Medicare also covers up to 2 individual 20 to 30 minute, face-to-face, high-intensity behavioral counseling sessions each year for sexually active adults.
Provided the counseling sessions are administered by a primary care doctor and take place in a primary care setting, such as a doctor’s office, Medicare will cover these counseling sessions.
If the counseling session is in an inpatient setting, the sessions won’t have coverage as Medicare Preventative Services.
Hepatitis B Virus Shot and Screening
Part B covers the hepatitis B shot if you’re at higher risk for hepatitis B. If your doctor accepts Medicare assignment, you pay nothing.
Medicare considers you high-risk if:
- Suffer from End-Stage Renal Disease
- You have hemophilia
- Reside in the same house as a hepatitis B carrier
- Have unprotected sex with various partners or with someone who suffers from hepatitis B
- Use specific illegal drugs
- You’re a health care employee in contact with blood and other body fluids at work
Medicare covers certain people at medium or high risk for Hepatitis B. You must get all three shots. Check with your doctor to find out if you qualify and when you should get them.
Since other factors could increase your risk for Hepatitis B, you should check with your doctor to see if you’re at risk for Hepatitis B.
Hepatitis C Screening Test
Part B includes one hepatitis C screening if your doctor requests the test. Those at risk can have one testing ever year with coverage.
Some potential indicators include:
- If you were born between 1945-1965
- Has a blood transfusion before 1992
- High-risk because of current or previous history using injectable and illegal drugs
Hepatitis C screenings have 100% coverage if screens are with a doctor that accepts Medicare. You only have coverage if the doctor orders testing.
Human Immunodeficiency Virus Screening
Part B covers a Human Immunodeficiency Virus (HIV) screening once a year if you’re between the ages of 15-65 or you have an increased risk. If you’re pregnant, you can have the screening up to 3 times during your pregnancy.
High-Risk Factors Include:
- Men that had sex with men after 1975
- Women and Men having unprotected sex with multiple partners
- past or present injection drug use
- People with previous or current partners that were HIV-infected, bisexual, or injection drug users
- Women or Men that exchange sex for money or drugs or who have partners that have
- History of blood transfusion between 1978 and 1985
- Individuals being treated for STDs
- Individuals requesting an HIV test despite reporting no risk factor
As long as the doctor accepts Medicare Assignment, you’ll pay nothing for the annual exam.
Medicare Preventive Services for Prostate Cancer Screening
Part B covers one prostate cancer screening each year for men over the age of 50. Medicare will cover these tests once every 12 months.
The review generally includes:
- A digital rectal examination
- Prostate-specific antigen test
After the yearly Part B deductible, you pay 20% of the amount for the digital rectal exam. You pay nothing for the PSA test.
Should your doctor determine you need a diagnostic prostate cancer screening, you’ll pay 20% of the costs.
Talk to your doctor or practitioner about whether you’re at risk for prostate cancer.
Medicare Mammogram and Breast Cancer Screening
Women over 40 need an annual mammogram screening to detect any abnormal tissue or breast cancer. Also, a woman qualifies for one baseline mammogram between the ages of 35 and 39. Men don’t qualify for preventive mammogram screenings. But, if a doctor finds an abnormality or lump, Medicare will cover diagnostic testing.
The risk of developing breast cancer increases if any of these apply:
- Never had a baby
- Had your first baby after age 30
- You had breast cancer in the past
- Family history of breast cancer
Medicare covers 100% of the cost of breast cancer screenings. Those with Medicare Advantage coverage have the same benefits as those with Medicare; but, you may need to see an in-network doctor.
Diagnostic mammograms will cost you 20% after you meet the Part B deductible. Those with Medicare Advantage plans will pay the plan’s cost-sharing amount.
If you have Medigap, the diagnostic mammogram cost could be little to nothing, depending on your policy. Breast cancer is the second leading cause of cancer death in women in America.
With age, the risks increase. Medicare covers mammogram screenings and digital technologies to check for breast cancer.
Well Woman Exam and Cervical Cancer Screening
Part B covers a pap smear and pelvic exam every two years. Those with a high risk of cervical or vaginal cancer can have screenings every 12 months.
Your risk for cervical or vaginal cancer is higher if:
- Sexually active before age 16
- Had five or more sexual partners
- Had a Sexually Transmitted Infection
- Your mom was given the drug Diethylstilbestrol during pregnancy
- You had fewer than three negative pap smears or no pap smear within the past seven years
When you use a participating provider, Medicare covers 100% of the cost of the exam if you’re eligible.
Colorectal Cancer Screening
Colorectal cancer screenings are preventive tests that identify health conditions. Part B covers colorectal cancer screens.
The screening options are as follows:
- Colonoscopy – Medicare covers once every 24 months if you’re high-risk, and once every ten years if you’re low-risk.
- Fecal occult blood tests – Medicare will cover this screening one time per year if you’re over 50 years old
- Barium enema – Medicare covers once every 24 months if you’re high-risk and over the age of 50. If you’re low-risk and over 50, Medicare will cover once every 48 months
- Flexible sigmoidoscopy – Medicare covers this test once every 48 months if you’re high-risk and over 50, or once every ten years if over 50 and low-risk
What could indicate that you’re at risk for colorectal cancer?
- Having a family history of this particular health condition
- Previously having colorectal cancer or polyps
- If you’ve already dealt with inflammatory bowel disease
Medicare will cover colonoscopies, fecal occult blood screens, and flexible sigmoidoscopies at 100%. Barium enemas Medicare covers, but only 80% of the cost.
Lung Cancer Screening
Screenings for lung cancer include a Low-Dose Computed Tomography scan of your chest. Chest scans are once a year.
Part B covers annual scans if:
- You’re between the ages of 55-77
- You smoke or were a smoker at all within the last 15 years
- You’re a “one pack a day” smoker for a minimum of 30 years
- You receive your lung cancer screening at a Medicare-approved facility
- You have no visible symptoms of lung cancer
Before referring you to your first lung cancer screening, your doctor will discuss both risks and benefits of the scan with you. You’ll also receive counseling for smoking, if appropriate. Medicare covers lung cancer screens at 100%.
Medicare Preventive Services for Tobacco Use Cessation Counseling
The U.S. Surgeon General reports that quitting smoking and stopping other forms of tobacco reduces the risk of certain diseases. Also, any person who uses tobacco can get counseling from a doctor. Part B covers two smoking cessation attempts every year if you use tobacco. Counseling includes up to four in-person sessions with your doctor. You can get a total of 8 sessions. If you’re eligible, Medicare will cover smoking cessation services at full cost.
Medicare Preventive Services for Shots
Flu shots may help limit seasonal influenza. Part B benefits cover one flu shot each flu season. Flu season runs typically from November – April. Depending on when you want to get your flu shot, Medicare might include a flu shot twice in one year. Medicare covers flu shots at 100%.
Part B benefits cover the Pneumococcal Shot. Most people only need the pneumococcal shot once. A second shot has coverage 11 months after the first. It’s best to discuss your options with your doctor. If your doctor accepts Medicare assignment, you pay nothing.
Medicare doesn’t cover the shingles shot. You’ll need Part D drug coverage for this vaccine. Contact your drug plan for information on coverage. Most plans cover the Shingrix or the Zostavax vaccine at 50%, but there may be a plan in your area that has more coverage.
Chronic Care Management Services
Medicare might cover a doctor to help you manage two or more chronic severe conditions if those conditions are going to last a year. There might be a monthly fee; the Part B deductible and coinsurance apply. Chronic care management can help you manage conditions like arthritis, heart disease, hypertension, asthma, osteoporosis, diabetes, and mental health conditions.
The doctor will help you manage your medication, prepare a care plan, and provide you with 24/7 urgent care access. Talk to your doctor about chronic care management services.
Medicare Advantage and Preventive Services
Medicare covers preventive care services; therefore an Advantage plan must also include these services. If you meet the necessary criteria, you can get preventive services.
How to Get Preventative Services Covered 100% with Medicare
We hope you found this list of Medicare Preventive Services for 2021 helpful! Most preventive care services have coverage for 100%. However, some diagnostic services require you to pay a copayment, coinsurance, or deductible. For situations such as this, Medigap coverage will pick up some costs.
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