Medicare and preventive care
April 1, 2022 | View PDF
Preventive care is the care you receive to prevent illness, detect medical conditions and keep healthy. A service is considered preventive if you have no prior symptoms of the disease. In contrast, diagnostic services address symptoms or conditions that you already have. Today we will discuss how Medicare covers preventive care.
Medicare Part B covers many preventive services, such as screenings, vaccines, and counseling. A list of these services is available at: https://www.medicare.gov/coverage/preventive-screening-services. If you have a question about whether Medicare covers your test or preventive service, you can visit http://www.medicare.gov, review your copy of the 2022 “Medicare & You” handbook, or download the “Medicare What’s Covered” app.
You should pay nothing for most preventive services so long as you see a provider who accepts Medicare assignment under Original Medicare. In some cases, you may be charged copays for services you receive that are related to your preventive service, even if Medicare pays for 100% of the cost of the preventive service itself.
During your preventive visit, your provider may discover and need to investigate or treat a new or existing problem. This additional service may be diagnostic or involve treatment. Medicare covers diagnostic and treatment services differently than preventive services, and you may be charged coinsurances or copays.
Medicare covers one ‘Welcome to Medicare’ preventive visit in your first year of having Medicare Part B, then one Annual Wellness visit per year after that, with zero cost-sharing. Keep in mind that these visits are not head-to-toe physicals. During the Welcome to Medicare visit, your provider will review your medical and social history as well as your health status and risk factors. Your provider will then give you resources related to your risk factors and health needs and will give you a checklist or written plan with information about other preventive services you may need. Annual Wellness visits, which Medicare will cover once you have had Part B for 12 months, are yearly appointments with your primary care provider to create or update a personalized prevention plan. This plan can help prevent illness based on your current health and risk factors. For both kinds of preventive visits, be prepared with information about your medical history, family history, the providers you see, durable medical equipment you use, and medications you take.
You pay nothing for most preventive services if you see a provider who accepts assignment under Original Medicare. These providers accept Medicare’s approved amount as payment in full. For preventive services that Medicare covers at 100%, you owe no deductible or coinsurance when you see a provider who accepts assignment. And if you receive services that do have a cost, these providers cannot charge you more than the Medicare-approved deductible and coinsurance.
If you see other types of providers, such as one who is out-of-network or one who does not accept assignment, then charges may apply to preventive care services that otherwise would not have cost you anything.
Check for fraud, errors
You can detect errors or fraudulent charges by carefully reviewing your health care statements from Medicare. If you think you were charged for a preventive service and should not have been, contact your health care provider first.
Claim summaries and medical bills can be confusing, so it is usually a good idea to ask your provider questions before reporting activity as potentially fraudulent. For example, you can call your doctor’s office and ask, “Can you explain why I was billed this amount for this service?” Additionally, some providers are not familiar with the full list of Medicare-covered preventive services, and they may have made a simple mistake from their lack of knowledge about the benefits. If you alert them to an error, the billing office should be able to correct it.
If you still believe you have experienced potential fraud or abuse, or if you have additional questions about this, you can contact our office and speak with one of our certified counselors who are trained as part of the nationwide Senior Medicare Patrol, or SMP, to help you prevent, detect and report health care fraud, errors and abuse.
For answers to any Medicare related questions, please feel free to contact the State of Alaska’s Medicare Information Office at 800-478-6065 or 907-269-3680; our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP) and the Medicare Improvements for Patients and Providers (MIPPA) program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor at the Alaska Medicare Information Office.