Navigating Medicare’s Preventive Care Benefit Many older adults remain unaware of the surprising array of Medicare benefits that are available before they ever get sick.

By Joel Mekler

NUMBER 78 / VOL. 1, 2020

www.csa.us Copyright 2020 Society of Certified Senior Advisors

Many older adults remain unaware of the surprising array of Medicare benefits that are available before they ever get sick. BY JOEL MEKLER

Next year will mark the fifty-fifth anniversary of one of the federal government’s most criti-cal social insurance programs: Medicare. Its

goal is to improve the health and well-being of older people while protecting individuals and families from the catastrophic costs of medical care. Medicare also protects hospitals from losses accrued while caring for uninsured patients — the largest number of whom are sixty-five and older.

Navigating Medicare’s Preventive Care Benefit

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Over the years, traditional Medicare (also known as Original Medicare or fee-for-service Medicare) has evolved to embrace many things: home health services, hospice care, skilled nursing care, Medicare Advantage (Part C), and prescription medications (Part D). However, Medicare was a late bloomer in covering preventive services like immunizations, screening tests, and counseling to prevent the onset or progression of disease and disability. Historically, Medicare only provided coverage for diagnostic and treatment services, not preventive services — which were statutorily excluded by law.

Original Medicare vs. Medicare AdvantageBefore addressing preventive care services, it’s worth-while noting some basic differences between Origi-nal (traditional) Medicare and Medicare Advantage. People with Medicare can get their health coverage through either Original Medicare or a Medicare Ad-vantage plan (also known as Medicare private health plan or Part C). Here are a few key differences be-tween these two options.

Original Medicare: Includes Part A (inpatient/hospital coverage) and Part B (outpatient/medical coverage).

• Beneficiaries can enroll in a Medicare supplement plan (“Medigap” policy).

• It’s widely accepted by most health care providers.

• Medicare limits how much an individual can be charged when visiting participating or non-participating providers.

• Beneficiary receives a red, white, and blue card to show to providers when receiving care.

Medicare Advantage: Private insurers who con-tract with the federal government to provide Medi-care benefits to beneficiaries.

• It must offer the same benefits as Original Medi-care; however, different cost-sharing and rules apply.

• It may provide additional benefits like dental, hearing, and vision care not covered by Original Medicare.

• Cost-sharing varies depending on the plan you choose.

• Most plans include prescription drugs.

• Beneficiaries cannot enroll in a Medicare supple-ment plan.

• Generally, beneficiaries must see in-network providers.

• Beneficiary uses one card for all medical and pre-scription drug benefits.

Preventive Care ServicesPreventive health services essentially fall into three categories (Center for Medicare Advocacy, 2012):

1. Screening for health problems that are not yet causing symptoms noticeable to the patient. This includes some forms of cancer screening, as well as screening for conditions like high blood pres-sure or high blood sugar, which generally don’t cause symptoms.

2. Checking for common problems that do cause symptoms but are easily overlooked in routine clinical care. This includes asking patients about things like depressive symptoms, falls, or even checking for signs of alcohol misuse.

3. Administration of vaccines or medications to re-duce the risk of future illness, such as the flu shot.

Affordable Care Act ProtectionsMedicare’s coverage for preventive services is a recent phenomenon. The biggest change occurred through the Patient Protection and Affordable Care Act (ACA) of 2010, which greatly expanded the number of Medicare preventive services while eliminating cost sharing (including no deductibles and/or copayments).

The ACA allows a Welcome to Medicare visit dur-ing the first twelve months beneficiaries are enrolled in Medicare Part B. The visit includes recording the patient’s height, weight, and blood pressure as well as an electrocardiograph, with the goal of health pro-motion and disease detection. The visit also includes education, counseling, and referral to other preven-tive services that the patient may need. It’s important to note that the Welcome to Medicare visit is not a physical exam and does not include clinical laboratory tests (Families USA, 2012).

The ACA also added an Annual Wellness Visit. This visit, again, is not an annual physical, but consists of the following (National Council on Aging, 2016):

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• An assessment to establish or update a patient’s medical and family history; list current providers and suppliers involved in the patient’s care (in-cluding a list of prescribed medications); record height, weight, body mass index, blood pressure, and other routine measurements; and indicate cognitive impairment, if any.

• Establish a five- to ten-year preventive services screening schedule based on the patient’s health status and age-appropriateness.

The ACA funds the federal government’s invest-ment in prevention through the Prevention and Pub-lic Health Fund, which is the nation’s first and only mandatory funding stream dedicated to improving public health. The goal is to pay for community out-reach and drive transformative change from a health care system that is largely treatment-focused to one that encourages healthy behaviors.

New Medicare Advantage BenefitsBeginning in 2019, Medicare Advantage plan provid-ers were given greater flexibility to offer “non-medical” benefits to members with specific chronic conditions. The goal is to help improve access to care and reduce avoidable hospitalizations and institutional place-ments. These benefits, which are not currently available in traditional Medicare, help enrollees of Medicare Advantage plans remain safely in their own homes, avoid social isolation, and lead longer, healthier lives.

To be eligible for payment under Medicare, items or services must: fall within a defined Medicare bene-fit category; be “reasonable and necessary” for diagno-sis or treatment; and not be statutorily excluded from coverage. The statute vests the authority of the Secre-tary of the U.S. Department of Health and Human Services( DHHS) to specify which items or services are covered in a defined benefit category and under what conditions. Medicare law has been amended several times to add new coverage, including coverage of certain preventive health care services.

Medicare will pay for most commonly performed cancer and other screenings in accordance with the rec-ommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices. Both agencies weigh evidence by conducting a systematic review of available literature on the use of preventive services in clinical practice, and its effects on health outcomes. Based on their reviews, the USPSTF has a letter grading system as shown below. Only those preventive services with a grade A or B are recommended for adoption by the USPSTF (Agency

for Healthcare Research and Quality, 2019).

• Grade A: The USPSTF recommends the service. There is a high certainty that the net benefit is substantial. Providers should offer or provide this service.

• Grade B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Providers should offer or provide this service.

• Grade C: The USPSTF recommends against routinely providing the service. There may be con-siderations that support providing the service for an individual patient. There is at least moderate certainty that the net benefit is small. Providers should offer or provide this service only if other considerations support the offering or providing the service in an individual patient.

• Grade D: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Providers should discour-age the use of this service.

• I Statement: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Providers should read the clinical considerations section of the USPSTF Recom-mendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits versus harms.

Preventive Services Covered by MedicareMedicare’s coverage of preventive services has in-creased substantially. Some services have not been en-dorsed by the USPSTF because research has proven that detecting certain problems will not lead to a better outcome. For instance, screening for prostate cancer by checking prostate-specific antigen levels in older men is no longer considered the preferred practice. This screening was not found to save lives and caused men to undergo many painful biopsies without ben-efit. Some preventive health services become optional or are recommended against when a patient reaches a certain age and is in poor health. For example, some

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screenings for a 65-year-old patient in good health would not be appropriate for an Alzheimer’s patient in the mid-eighties (Graham, 2012).

2019 MEDICARE PREVENTIVE BENEFITS THAT ARE NOT SUBJECT TO COINSURANCE OR DEDUCTIBLE (CMS 10110, 2019):

Mental health, cognitive health, and substance use screenings

• Depression screening

• Smoking & Tobacco use cessation

• Alcohol misuse counseling

Physical Health and Disease Screenings

• Cardiovascular

• Diabetes

• Sexually transmitted diseases infections

• Abdominal aortic aneurysm

• HIV

• Obesity

• Bone mass measurements

• Pap test and pelvic exams

• Welcome to Medicare Visit (One-time visit available for new Medicare beneficiaries enrolled in Part B. Must occur within the first twelve months).

• Annual Wellness Visit (for participants enrolled in Part B for longer than twelve months).

Cancer Screenings

• Colorectal cancer

• Breast cancer

• Lung cancer

• Cervical cancer

Vaccinations

• Flu

• Pneumonia

• Shingles (covered under Medicare Part D pre-scription drug coverage)

• Hepatitis C (if at risk)

• Hepatitis B (if at risk)

Counseling and Education

• Medical nutrition therapy services

• Behavioral therapy (One visit per year with a pri-mary care doctor covered to help lower the risk of cardiovascular disease).

• Advanced care planning is a new benefit added in 2016 which includes completion or review of advance directives.

Services Original Medicare covers subject to coin-surance and/or deductible:

• Prostate cancer screenings

• Glaucoma tests

• Diabetes self-management training (This is cov-ered for people with diabetes with a written order from a doctor).

MEDICARE COVERAGE RULES FOR PREVENTIVE SERVICES

1. Original Medicare Part B will cover preventive services at 100 percent as long as the doctor ac-cepts assignment, meaning the doctor agrees to the payment terms of Medicare. Approximately 93 percent of all doctors in America accept Medicare. Some physicians decide to opt out of Medicare. Opt out is a contract between a provider, beneficiary, and Medicare where the provider or beneficiary does not file a claim to Medicare. Instead, the physician or practitioner bills the beneficiary directly and is not required to follow the fee-for-service charges determined by Medicare. Medicare Advantage plans generally follow the same rules as Original Medicare when

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it comes to preventive services. The only differ-ence is that Medicare Advantage plan members must be seen by an in-network provider or they may be responsible for the full cost (Medicare Rights Center, 2014).

2. Some preventive care services may have 80/20 cost sharing, even when they’re covered under Medicare Part B. Keep in mind that each preven-tive service has its own eligibility requirements and guidelines. Medicare may only cover a service a certain amount of times each year or under spe-cific circumstances. Typically, patients are respon-sible for paying the deductible and 20 percent coinsurance. If patients are enrolled in a Medicare Advantage plan, they will likely have a copay or coinsurance. Glaucoma screenings, diabetes self-management trainings, barium enemas, and digital rectal exams fall into that category.

3. An additional expense sometimes associated with preventive service visits is a facility fee. This is a charge that beneficiaries may have to pay when they see a doctor at a clinic that is not owned by that doctor. Facility fees are charged in addition to any other charges for the visit and are subject to coinsurance. They are often charged at clinics that are owned by hospitals to cover the costs of maintaining that facility. Always check with the Medicare Advantage plan first to see if it pays for facility charges. If a doctor performs a diag-nostic procedure either before or after a patient’s preventive screening, the diagnostic part of the visit will be billed separately. For example, if the patient has a colonoscopy (a preventive service) and the doctor finds or removes a polyp during the same visit, there may be a separate charge for the removal of the polyp. Some states have taken action against such “surprise” bills and have eliminated the charge for any diagnostic work performed during the colonoscopy.

4. Separate eligibility requirements apply for cer-tain preventive services based on a patient’s age, gender, risk factors, and frequency. Beneficiaries should check with their doctor first to see if they meet the guidelines.

Future DirectionsImproving the health of a population requires health systems, health plans, not-for-profit health organiza-tions, and government payers to work collaboratively in impactful ways to develop strategies and investment

approaches that address the drivers of health (also known as social determinants) (Fried, 2015). Treat-ing an illness often doesn’t take into consideration any of the social and contextual factors that caused it (e.g., limited access to nutritious food, lack of exercise, unsafe or unstable living conditions, poor air quality). A growing number of health-care stakeholders are beginning to pay closer attention to these drivers of health and their connection to health outcomes. This shift in focus could help drive meaningful, sustain-able change that impacts the health of individuals and their communities.

Medicare has been remarkably adaptable in the face of health-care changes and partisan politics. The program still has a high satisfaction rate among bene-ficiaries. While stakeholders and government entities continue to invest in treating disease, public health’s science of prevention and promotion for older adults has been the missing link. Now, there seems to be growing interest to incorporate social determinants of health. One need only look at the various supplemen-tal benefits, such as long-term services and supports, that Medicare Advantage plans can now offer.

In 2019, Medicare Advantage plans began offer-ing a wide range of supplemental benefits due to a significant change in federal rules. These plans now have greater flexibility to design and tailor benefits like support for family caregivers, in-home support-ive services, meals, and other social determinants of health. Currently, the change is for Medicare Advan-tage enrollees only (CMS, 2019b).

While many view preventive services as a way to improve government healthcare, there is considerable debate about whether preventive benefits actually save Medicare money in the long term.

Financial ConsiderationsAlthough the Affordable Care Act made it easier and less expensive for older adults to stay healthy and better manage their chronic conditions, there are still substantial barriers around access. Low-income individuals and racial minorities are underutilizing preventive services when compared to the general population. The American Association of Retired Persons in collaboration with the John Hartford Foundation found that very few Medicare beneficia-ries are taking advantage of the Annual Wellness Visit (Gibson, 2018). The study found that 8.1 percent of Medicare beneficiaries took advantage of these free doctor visits when first eligible in 2011, including just 4.5 percent of African Americans. By 2013, the rate for all beneficiaries still remained less than 15 per-cent for older adults according to a Medicare Current

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Beneficiary Survey for years 2011-2013. The complexity of the Medicare program may

be another obstacle for people not receiving regular preventive services. As noted earlier, accessing preven-tive benefits can be difficult, particularly if the patient lacks health care literacy. And even though Medicare reimburses doctors about three times their ordinary office visit rate for conducting annual wellness visits, very few primary care doctors seem to have the time or lack knowledge of Medicare’s preventive benefit.

As the nation continues to get older, Medicare’s lack of coverage for routine dental, hearing, and vision care will become a growing issue. Congress needs to repeal the statutory exclusion of Medicare coverage for these services. This lack of coverage can lead to health issues resulting from various complications. For instance, diabetes and cardiovascular disease are associated with a lack of appropriate dental care. Vi-sion loss is the third-leading chronic condition among older adults and can lead to depression, decrease of cognitive function, and increase of injuries due to falls. And hearing loss negatively affects nearly 66 percent of older adults by socially isolating them.

ConclusionThe United States spends far more on medical care than any other industrialized nation, yet ranks twen-ty-sixth out of forty-three countries in life expectancy. Unfortunately, only 1 percent of the nation’s health-care spending is focused on prevention and public health, despite the fact that chronic conditions — the most common, costly, and preventable of all health problems — account for 90 percent of health-care costs. Several public health experts believe that ex-tending preventive care to all adults beginning at age fifty will optimize the health of all older Americans.

The Affordable Care Act ushered in a new era of prevention and wellness that can help save lives and money for beneficiaries as well. Further community outreach and education is needed to make seniors and health care professionals aware of this critical benefit. •CSA

Joel Mekler has more than thirty years of human resources and health insurance industry experience. After a long and rewarding career in public service, Joel currently serves as a Medicare counselor for the

Pennsylvania State Health Insurance Assistance Program. In this role, he advises Medicare beneficiaries, their families, and caregivers on a wide array of Medicare options. Joel has served as an insurance counselor during the start-up of the Affordable Care Act and the Medicare Part D Prescription Drug Program. Most recently, Joel has

been involved in the roll-out of a Medicaid Managed Care program known as Community Health Choices in Western Pennsylvania. In ad-dition, Joel writes a weekly column called “Medicare Moments” for a local newspaper. He received his certification as a CSA in 2011.

■ REFERENCESAgency for Healthcare Research & Quality. (2019, April). U.S.

preventive service task force ratings. Retrieved from: https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-ratings

Benson, W. F. & Aldrich, N. (2012). Centers for Disease Control and Prevention focuses on the need for older adults to receive clinical preventive services. Retrieved from https://www.cdc.gov/aging/pdf/cps-clinical-preventive-services.pdf

Centers for Medicare & Medicaid Services (CMS) 10110. (2019, August). Your guide to Medicare’s preventive services. Retrieved from: https://www.medicare.gov/Pubs/pdf/10110-Medicare-Preventive-Services.pdf

Centers for Medicare and Medicaid Services. (n.d.). Preventive and screening services. Retrieved from https://www.medicare.gov/coverage/preventive-screening-services

Centers for Medicare & Medicaid Services. (2019a, September) Are you up-to-date on your preventive services? Retrieved from https://www.medicare.gov/Pubs/pdf/11420-Preventive-Services-Card.pdf

Centers for Medicare & Medicaid Services. (2019b, September). Medicare & you. Retrieved from https://www.medicare.gov/pubs/pdf/10050-medicare-and-you.pdf

Center for Medicare Advocacy. (2012, September 20). Making sense of Medicare’s preventive service benefit. Retrieved from https://www.medicareadvocacy.org/making-sense-of-medicares-preventive-service-benefits/

Families USA. (2012, February). An advocate’s guide to the annual wellness visit benefit in Medicare. Retrieved from https://familiesusa.org/sites/default/files/product_documents/Advocate-Guide-Medicare-Wellness-Visit.pdf

Fried, L. P. (2015, June). A prescription for the next 50 years of Medicare. Generations. Retrieved from https://www.asaging.org/blog/prescription-next-fifty-years-medicare

Gibson, W. (2018, August 15). Few Medicare patients make use of free wellness visits. Retrieved from https://www.aarp.org/health/medicare-insurance/info-2018/medicare-free-annual-wellness-visits.html

Graham, J. (2012, April 24). Doctors fall short in helping many seniors. Retrieved from https://khn.org/news/poll-doctors-fall-short-in-helping-many-seniors/

National Council on Aging. (2016, April). A closer look: Medicare’s annual wellness visit. Retrieved from https://www.ncoa.org/wp-content/uploads/medicare-annual-wellness-visit.pdf

U.S. Preventive Services Task Force. (n.d.). Recommendations for primary care practice. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations

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