Prevention in Medicare

On this page: Budget

Background

The goals of prevention are to promote good health (primary prevention) and detect disease at early stages when it is most treatable (secondary prevention). To help achieve these goals, Congress added a new physical exam visit benefit to Medicare. The benefit, called Welcome to Medicare, provides beneficiaries with a one-time preventive physical examination. Beneficiaries can receive this benefit within the first 12 months of becoming eligible for Medicare Part B. For this exam, the annual Part B deductible and patients’ 20 percent coinsurance are waived.

The ACA also created a new prevention benefit—an annual wellness visit for Medicare beneficiaries with no deductible or copayment. The visit must include a comprehensive health risk assessment—with both an individual and a family medical history—and a personalized prevention plan.

The ACA further supports the use of preventive services for Medicare beneficiaries by waiving cost-sharing for preventive services that have a US Preventive Services Task Force rating of A or B. (The ACA also provides enhanced federal funding to states that eliminate cost-sharing for recommended preventive services in their Medicaid programs.) In addition the ACA waives Medicare Part B cost-sharing for vaccines recommended by ACIP, however, cost-sharing for ACIP-recommended immunizations is not waived in Medicare Part D.

Although all Medicare beneficiaries underutilize many proven preventive services, racial and ethnic groups that have experienced discrimination underutilize these services to a greater degree. In an effort to better address disparities in health care, the ACA requires HHS to ensure that any federally conducted or federally supported health care or public health effort collects and reports data on race, ethnicity, and primary language. The law requires HHS to develop standards for collecting these data to provide statistically reliable population estimates. Another way to reach underserved populations is to provide information about preventive services in senior centers and other congregate facilities, such as affordable housing.

Prevention in Medicare: Policy

Community outreach

In this policy: FederalLocalState

To increase the number of Medicare beneficiaries who take advantage of covered preventive services and screenings, federal, state, and local governments should fund community-based outreach, education, and promotion efforts that include targeted initiatives for at-risk beneficiaries.

Outreach, education, and promotion efforts should be culturally competent and language accessible. In addition, to the extent possible, these efforts should be evidence-based. States and localities have a vested interest in doing this because they provide funding, often through care coordination arrangements, for dual-eligibles (e.g., Medicare beneficiaries who are also eligible for Medicaid).

Cost-sharing for preventive services

In this policy: Federal

HHS should make A- and B-rated preventive services available without cost-sharing only for those beneficiaries for whom the US Preventive Services Task Force finds evidence to support such provision. ACIP-recommended adult vaccines should also be made available without cost-sharing in Medicare Part D.

Research

In this policy: Federal

Congress should continue to adequately fund research to identify and evaluate appropriate preventive and screening services that Medicare does not cover.

Comprehensive risk assessment

In this policy: Federal

The federal government should ensure that an assessment of medical and family history for purposes of developing a comprehensive risk assessment includes: cognitive ability, diet and exercise history, depression screening, substance use history, and social and sexual history.

Research on utilization of preventative services

In this policy: FederalLocalState

Federal, state, and local governments should take a leadership role in funding research to identify and address why proven Medicare-covered preventive services are underutilized in the general Medicare population and among racial and ethnic groups that have experienced discrimination. In addition each level of government should fund targeted research to identify the causes for underuse of clinically indicated preventive services among the general population and among racial and ethnic groups that have experienced discrimination.

Special care should be taken to include older adults with disabilities and, where appropriate, people with chronic conditions in this research.

In developing standards for the collection of data on race and ethnicity, the federal government should take steps to ensure that such data reflect statistically reliable population estimates by, among other things, developing criteria for whether and how such methods as geocoding and surname analysis may be used, as well as when the use of such strategies is contraindicated.