Preventive Services in Medicare

Background

There are two main types of prevention. In primary prevention, the goal is to promote good health. In secondary prevention, the goal is to detect disease at early stages when it is most treatable. To help achieve both these goals, the Affordable Care Act (ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. ) introduced Medicare’s Welcome to Medicare Visit, a one-time preventive physical examination within the first 12 months of becoming eligible for Medicare Part BThis program covers services not covered by Part A, primarily physician and other outpatient services, medical equipment, and ambulance services. People eligible for Medicare Part A may voluntarily enroll in Part B by paying a monthly premium.. Annual wellness visits are available thereafter. These exams, which are not subject to a deductibleThe amount that individuals must pay for services covered under an insurance plan before the insurer pays benefits. Not all out-of-pocket spending counts toward the deductible. or copayment, must include a comprehensive health risk assessment and the development of a personalized prevention plan. Medicare also waives deductibles or copayments for other preventive care that meets certain criteria. Cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. is also waived for preventive services that have a U.S. Preventive Services Task Force rating of A or B. The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. also provides enhanced federal funding to states that eliminate cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for recommended preventive services in their Medicaid programs. In addition, the ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. waives Medicare Part BThis program covers services not covered by Part A, primarily physician and other outpatient services, medical equipment, and ambulance services. People eligible for Medicare Part A may voluntarily enroll in Part B by paying a monthly premium. cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for vaccines recommended by the Advisory Committee on Immunization Practices. Vaccines covered under Medicare Part D are not exempt from cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services..

Although all Medicare beneficiaries underutilize many evidence-based preventive services, this is more pronounced among historically disadvantaged racial and ethnic groups. To address the disparity, the ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. requires federally conducted or federally supported health care activities or public health efforts to collect and report data on race, ethnicity, and primary language. The law requires the Department of Health and Human Services 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.

PREVENTIVE SERVICES IN MEDICARE: Policy

PREVENTIVE SERVICES IN MEDICARE: Policy

Community outreach

Federal, state, and local governments should fund community-based outreach, education, and promotion efforts that include targeted initiatives for at-risk and underserved beneficiaries. The aim is to increase the number of Medicare beneficiaries who use covered preventive services and screenings.

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

The Department of Health and Human Services should make A- and B-rated preventive services available without cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. only for those beneficiaries for whom the U.S. Preventive Services Task Force finds evidence to support such a provision. Vaccines recommended by the Advisory Committee on Immunization Practices should be made available without cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. in Medicare Part D.

Research

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

 

Comprehensive risk assessment

The federal government should ensure that an evaluation 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 preventive services

Federal, state, and local governments should fund research to better understand why evidence-based Medicare-covered preventive services are underutilized in the general Medicare population, particularly among historically disadvantaged groups.

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. They should develop 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.