Medicare Preventive Services

Medicare covers a range of preventive services to keep you healthy.

Preventive services can help find health problems early, when treatment is most effective, and can keep you from getting certain diseases. Medicare also covers two key visits with your health care provider — Welcome to Medicare and Annual Wellness Visit.

How much will it cost you?

Most preventive services are at no cost to you if you are covered by Part B. You may have costs for some preventive services if your physician or health care provider makes a diagnosis during the visit or orders additional tests. Talk to your provider to understand why the exam or tests are necessary, and if it isn’t covered, and you think it should be, you may appeal the determination.

Note: If you are covered by a Medicare Advantage Plan (HMO or PPO) you need to check with your plan for co-payment or co-insurance amounts, if applicable.

Remember you can help prevent illness by:

  • Exercising

  • Eating well

  • Keeping a healthy weight

  • Not smoking

  • Getting preventive services

Preventive Services Coverage & Eligibility

Preventive services includes exams, shots, lab tests, screenings, and programs for health monitoring, and counseling and education to help you take care of your own health. This table lists the types of preventive services and summarizes eligibility requirements and guidelines. The “Cost to you” section assumes you receive services from a provider that accepts Medicare assignment. The 20% co-insurance amounts apply to beneficiaries with Original Medicare, and the Part B deductible may apply. HMO and PPO plan members need to check with their plan for the applicable co-payment amount, if any.

An aneurysm that grows and becomes large enough can burst, causing dangerous, often fatal bleeding inside the body. More than 15,000 people a year die from ruptured aortic aneurysms. If found early, many aneurysms can be treated before they rupture. Because aneurysms can develop and become large before causing any symptoms, it is important to look for them in people who are at the highest risk.

Who is covered: Individuals with family history or man 65 to 75 and have smoked at least 100 cigarettes in their lifetime

How often is it covered: One time referral at “Welcome to Medicare” visit (see “Welcome to Medicare” section)

Cost to you: Zero

Over 3 million individuals who abuse alcohol in the U.S. are over age 60. Currently, 1 in 8 people in the United States has a drinking problem. This screening can help prevent you from becoming dependent on alcohol.

Who is covered: Adults w/Medicare who use alcohol but do not meet medical criteria for alcohol dependency

How often is it covered: One alcohol misuse screening per year. Up to 4 brief face-to-face counseling sessions per year (if determined misusing alcohol)

Cost to you: Zero

Bone mass measurements help your doctor tell if you are at risk for a broken bone (fracture). Test results will help you and your doctor choose the best way to keep your bones strong.

Who is covered: Certain people with risk for osteoporosis

How often is it covered: Once ever 24 months

Cost to you: Zero

Breast cancer is the most invasive cancer in women. However, breast cancer survival rates are rising as screening and treatment improve. Because risk increases with age, it is important to continue with screening, even if you were screened before you entered Medicare.

Who is covered: Women 40 and older

How often is it covered: Every 12 months

Cost to you: Zero

Cardiovascular disease generally refers to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain (angina) or stroke. Other heart conditions, such as those that affect your heart’s muscle, valves or rhythm are also considered forms of heart disease.

Your doctor can ask you a series of questions to see if you are at risk for developing heart disease. If so, your doctor can help you learn ways to make lifestyle changes, like changing your diet to help you stay healthy.

Who is covered: All people with Medicare

How often is it covered: Once every 5 years

Cost to you: Zero

Behaviorial therapy

Who is covered: All people with Medicare

How often is it covered: Once each year

Cost to you: Zero

Cervical and vaginal cancers are cancers of the womb and birth canal. Regular pelvic exams and Pap tests help prevent these cancers. Your doctor can find abnormal changes in the cervix and vagina and treat you before cancer develops. Women who do not regularly have Pap tests have an increased risk of cervical cancer.

Who is covered: All women with Medicare

How often is it covered: Once every 24 months (or once every 12 months if high risk)

Cost to you: Zero

Colorectal cancer is more common in people over 50, and the risk increases with age. In the United States, it is the fourth most common cancer in men and women. Screenings can help find growths in the colon (pre-cancerous polyps) which can be removed before they turn into cancer. Treatment works best when colorectal cancer is found early.

Multi-target stool DNA test

Who is covered: All people 50 and older

How often is it covered: Once every 3 years

Cost to you: Zero

Screening barium enemas

Who is covered: All people 50 and older

How often is it covered: Every 48 months when used instead of colonoscopy or sigmoidoscopy & high risk

Cost to you: 20%

Screening colonscopies

Who is covered: All people 50 and older

How often is it covered: Once every 10 years (or 48 months after a previous flexible sigmoidoscopy); once every 24 months if at high risk

Cost to you: Zero

Screening fecal occult blood test

Who is covered: All people 50 and older

How often is it covered: Once every 12 months

Cost to you: Zero

Screening flexible sigmoidoscopies

Who is covered: All people 50 and older

How often is it covered: Once every 48 months but not within 10 years of screening colonoscopy, if not high risk

Cost to you: 20%*

1 in 6 individuals over the age of 65 suffers from depression. Many people who suffer from depression are not diagnosed or treated, which can lead to other health problems, even death. Left untreated, older adults are the highest at risk for suicide. This screening can help you get treatment to improve your quality of life.

Who is covered: All people with Medicare

How often is it covered: Once every 12 months

Cost to you: Zero

Diabetes is the seventh leading cause of death in the United States. Millions of people have diabetes and do not know it. If you have diabetes and your doctor finds it early, he or she may be able to help prevent or delay the serious health problems diabetes can cause.

Who is covered: People at risk for diabetes

How often is it covered: Up to 2 per year if dianosed with pre-diabetes

Cost to you: Zero

If you’ve been diagnosed with diabetes, this training teaches you to cope with and manage your diabetes.

Who is covered: People diagnosed with diabetes

How often is it covered: Up to 10 hours of initial DSMT; up to 2 hours follow-up training per year

Cost to you: 20%*

Glaucoma is a group of eye conditions that damage the optic nerve, which is vital to good vision. Glaucoma tests measure the pressure in your eye or the angle of your eye. If you find and treat glaucoma early, you can often protect your eyes from serious vision loss.

Who is covered: People at high risk for glaucoma

How often is it covered: Once every 12 months

Cost to you: 20%*

Hepatitis B is a liver infection caused by the Hepatitis virus. Your liver’s main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. It also detoxifies chemicals and metabolizes drugs.

Who is covered: People at high risk

How often is it covered: Once per year if continue at high risk and don’t get a Hepatitis B shot

Cost to you: Zero

Hepatitis C is a virus that spreads from person to person through blood and infects the liver. If left untreated, over time it can cause liver damage or liver failure.

Who is covered: People at high risk

How often is it covered: One time test, unless high risk, then every 12 months

Cost to you: Zero

HIV, or Human Immunodeficiency Virus, is a virus that attacks a person’s immune system. Our immune systems are made up of several types of cells and organs that help us fight off everyday infections and diseases. Once the virus is in your body, it can only be treated, not removed.

If you are at risk, it is important for you to get tested each year. That way, if you are infected, you can get help right away.  Yearly tests also help prevent the spread of HIV. More than 1 million Americans live with HIV/AIDS. But 1 in 5 people do not know they are infected.

Who is covered: People 15-65 years; older than 65 and at increased risk for HIV

How often is it covered: Once every 12 months

Cost to you: Zero

Lung cancer is the leading cause of cancer deaths in the United States, among both men and women. People who smoke have a greater risk of lung cancer,  and risk increases with length of time and number of cigarettes smoked.

Who is covered: Heavy smoker; no symptoms of cancer

How often is it covered: Once every 12 months

Cost to you: Zero

Medical nutrition therapy is an evidence-based approach to treating certain chronic conditions through the use of an individual-tailored nutrition plan.

Who is covered: People with diabetes or kidney disease; or had kidney transplant in last 36 months

How often is it covered: 1st year – 3 hours of 1-on-1 counseling; 2 hours each year after

Cost to you: Zero

Obesity, a common and costly health issue that increases risk for heart disease, type 2 diabetes, and cancer, affects more than one-third of adults. This screening can help you get treatment to improve your quality of life.

Who is covered: All people may be screened; counseling for anyone with body mass index of 30 or more

How often is it covered: Face-to-face sessions with your doctor or primary care practitioner

Cost to you: Zero

Prostate cancer is the second most common type of cancer in American men. A rectal exam and a blood test called a Prostate Specific Antigen (PSA) test can find this cancer.

Digital rectal exam

Who is covered: All men with Medicare over 50

How often is it covered: Once every 12 months

Cost to you: 20%*

Prostate specific antigen (PSA) test

Who is covered: All men with Medicare over 50

How often is it covered: Once every 12 months

Cost to you: Zero

Screening for sexually transmitted illnesses is important for sexually active adults of all ages. Medicare covers these tests to keep you healthy and diagnose and treat illnesses if necessary.

Who is covered: People at risk for an STI

How often is it covered: Once every 12 months. Two individual 20-30 minute, face-to-face, high-intensity behaviorial counseling sessions

Cost to you: Zero

Shots (vaccinations) help protect you from serious illnesses and can protect you from getting preventable diseases.

Flu

Who is covered: All people with Medicare

How often is it covered: Once per flu season

Cost to you: Zero

Pneumoccoccal

Who is covered: All people with Medicare

How often is it covered: Once in lifetime

Cost to you: Zero

Hepatitis B

Who is covered: People at medium or high risk of Hepatitis B

How often is it covered: 3 shots for complete protection

Cost to you: Zero

This counseling can help you quit smoking. If you stop smoking, you can significantly lower your risk for certain diseases, even if you have smoked for years.

Who is covered: Individuals who haven’t been diagnosed with an illness caused by tobacco use

How often is it covered: Up to 8 face-to-face visits during a 12-month period smoking

Cost to you: Zero

During the first year that you have Medicare Part B, you can get a one-time preventive visit with your medical provider. This visit is intended to review your medical and social history. It is also an opportunity for you and your physician to discuss your schedule of important screenings and shots.

Who is covered: New Medicare enrollees with Part B

How often is it covered: One-time preventive visit within first 12 months you have Medicare Part B

Cost to you: Zero

This annual “wellness” visit is intended to create or update your personalized prevention plan. This plan may help present or detect illness based on your current health and risk factors.

Who is covered: Medicare beneficiaries with Part B for more than 12 months

How often is it covered: Once every 12 months

Cost to you: Zero

“Welcome to Medicare” Preventive Visit

Medicare covers a one-time preventive visit within the first 12 months that you are enrolled in Medicare Part B. This Initial Preventive Physical Examination (IPPE), often referred to as the “Welcome to Medicare” visit, is intended to review your medical and social history. It is also an opportunity for you and your physician to discuss your schedule of important screenings and shots.

What happens at this visit?

During the visit, your physician will:
  • Record your medical and social history (e.g. your diet; activity level; use of alcohol or tobacco)

  • Record your height, weight, and blood pressure

  • Calculate your body mass index

  • Give you a simple vision test

  • Review your potential risk for depression and your level of safety

  • Offer to talk to you about creating advance directives. These are legal documents that allow you to put in writing the kind of health care you would want if you were too ill to speak for yourself.

What to bring to the visit?

  • Your medical records, including immunization records

  • Your family health history

  • A list of prescription and over-the-counter drugs that you currently take, including dosage and frequency

Who is covered and how often?

  • This visit is a one-time only benefit

  • Medicare beneficiary must complete this visit within first 12 months enrolled in Medicare Part B

What are the costs?

You pay nothing if your doctor accepts Medicare assignment

Is “Welcome to Medicare” the same as “Annual Wellness Visit”?

No, do not confuse the two (see Annual Wellness Visit description below). Both appointments are essential for identifying and treating potential health issues, but neither is a physical examination. You are responsible for any co-payments or co-insurance resulting from a physical exam.

Annual Wellness Visit

Medicare covers an “Annual Wellness Visit” to create or update your personalized prevention plan. This plan may help prevent or detect illness based on your current health and risk factors.

What generally happens at this visit?

During the visit, your physician will:
  • Record height, weight, and blood pressure and other routine measurements

  • Provide a health risk assessment

  • Review your medical and family history

  • Screen for any cognitive impairment

  • Screen for depression

  • Provide personalized health advice

  • Develop and discuss a list of risk factors and treatment options for you

  • Develop and discuss a screening schedule for appropriate preventive services

  • Develop or update your list of medications and durable medical equipment needs

What to bring to the visit?

Your list of questions or concerns that you wish to discuss with your health care provider

Who is covered and how often?

  • Medicare beneficiaries who have been enrolled in Medicare Part B at least 12 months

  • You did not receive your “Welcome to Medicare” or an Annual Wellness Visit within the past 12 months

  • Once every 12 months

What are the costs?

You pay nothing if your doctor accepts Medicare assignment

Contact HICAP for Assistance

(800) 434-0222 or (714) 560-0424
OR
Contact your closest Senior Center to schedule an appointment with a local HICAP Counselor

HICAP does not sell, endorse, or recommend insurance products.

This project was supported, in whole or in part, by grant number(s) 1801CAMISH, 1801CAMIAA, 1801 CAMIDR, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.

This project is funded in part through a grant from the California Department of Aging, as administered by the Office on Aging.