Preventive Services in Medicare

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, the ACA introduced Medicare’s one-time preventive physical examinations within the first 12 months of becoming eligible for Medicare Part B (the Welcome to Medicare Visit) and annual wellness visits thereafter. These exams, which are not subject to a 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-sharing is also waived for preventive services that have a US Preventive Services Task Force (USPSTF) rating of A or B. In addition, cost-sharing is waived for all immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) that are covered under Medicare Part B. Vaccines covered under Medicare Part D are not exempt from cost-sharing. The Affordable Care Act (ACA) further supports the use of preventive services for Medicare beneficiaries by waiving cost-sharing for preventive services that have a U.S. Preventive Services Task Force rating of A or B and 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 the Advisory Committee on Immunization Practices.

Although all Medicare beneficiaries underutilize many evidence-based preventive services, this is more pronounced among historically disadvantaged racial and ethnic groups. To address this disparity, The Affordable Care Act 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

Community outreach

In this policy: FederalStateLocal

Federal, state, and local governments should fund community-based outreach, education, and promotion efforts that include targeted initiatives for at-risk and underserved beneficiaries 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

In this policy: Federal

HHS should make A- and B-rated preventive services available without cost-sharing only for those beneficiaries for whom the U.S. Preventive Services Task Force finds evidence to support such provision. Recommended vaccines should be made available without cost-sharing in Medicare Part D. (Specifically those recommended by the Advisory Committee on Immunization Practices.

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 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

In this policy: FederalStateLocal

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 and 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 including by 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.