Which tests are covered under Medicare preventive screening? Medicare now has a long list of preventive screenings that are covered at no cost to the patient. But how often can you get these preventive screening tests? The answer varies from test to test.
I had a call today from a man who is new to Medicare and was asking about getting an annual physical. I told him Medicare does not cover what is called an “annual physical”, but it does cover lots of tests would be part of a physical. But I couldn’t tell him how often these Medicare preventive screening tests are allowed. So I decided to search for answers and I found them at Medicareinteractive.org. Here are a few of the common Medicare preventive screenings I checked out.
Blood tests for heart disease screening:
Medicare covers blood tests every five years to test cholesterol, lipid and triglyceride levels.
My note: If you have health issues or are taking drugs to lower your cholesterol, you would have your blood checked more regularly, but those tests would be coded as “diagnostic”, meaning you would have a 20% co-pay. This might be covered by your Medicare supplement, depending on which one you have. Medicare Advantage plans each have their own co-pay rules for diagnostic tests and lab services.
You are eligible for one Medicare-covered diabetes screening every 12 months if you:
- have hypertension;
- have dyslipidemia (any kind of cholesterol problem);
- have a prior blood test showing low glucose (sugar) tolerance;
- are obese (body mass index of 30 or more); or
- meet at least two of the following:
- you are overweight (body mass index between 25 and 30);
- you have a family history of diabetes;
- you have a history of diabetes during pregnancy (gestational diabetes) or have had a baby over nine pounds; or
- you are 65 years of age or older.
The Medicare-covered diabetes screening test includes :
- a fasting blood glucose tests; and/or
- a post-glucose challenge test.
If you have been diagnosed with pre-diabetes, Medicare will cover two diabetes screening tests a calendar year. Having pre-diabetes means you have blood glucose (sugar) levels that are higher than normal, but are not high enough to be classified as diabetes.
Bone mass measurements:
Medicare pays in full (no coinsurances, copays or deductibles) for this test once every two years for people whose doctor or other health care provider prescribed the test because they:
- Are an estrogen-deficient women who is at risk for osteoporosis based on her medical history and other findings
- Have vertebral abnormalities that were shown on an x-ray
- Have received daily steroid treatments for more than three months
- Have hyperparathyroidism
- Take an osteoporosis drug
Medicare will also cover follow-up measurements or more frequent screening if your doctor prescribes them.
If a person has no symptoms or prior history of breast cancer, Medicare will cover preventive mammograms. Medicare covers:
- One baseline mammogram for women 35 to 39 years of age
- One screening mammogram every 12 months for women ages 40 and over
Medicare will also pay for both men and women to have diagnostic mammograms more frequently than once a year. A diagnostic mammogram may be recommended when a screening mammogram shows an abnormality or when a physical exam reveals a lump. Medicare covers as many diagnostic mammograms as necessary. These mammograms are billed differently than preventive screening mammograms. There is a 20 percent coinsurance for people with Medicare who have already met the Part B deductible.
For women with Medicare who are considered at low risk for cervical or vaginal cancer, Original Medicare covers 100 percent of the cost of one Pap smear every two years (24 months).
For women who are of childbearing age and have had an abnormal Pap smear in the past 36 months Medicare covers the cost of one Pap smear a year (every 12 months). Medicare will also cover a Pap smear once a year for women who are considered at high risk of developing cervical or vaginal cancer. Women are considered at high-risk for cervical or vaginal cancer.
Since 2011, Original Medicare has covered Pap tests (including collection), pelvic exams (used to help find fibroids or ovarian cancers), and clinical breast exams with no coinsurance or deductible if you see doctors or other health care providers who accept assignment. Doctors who accept assignment cannot charge you more than the Medicare approved amount. People with Medicare also do not pay for Pap lab test fees.
Prostate cancer exam:
Medicare covers one prostate screening a year (every 12 months) for all male Medicare patients age 50 and older. This screening includes a Prostate-Specific Antigen (PSA) blood test and a digital rectal exam (DRE).
Medicare covers 100 percent of the cost of the PSA test (with no Part B deductible required) and 80 percent of the cost of the digital rectal exam (after you pay your annual Part B deductible). You will have no copay or deductible for the PSA test if you see doctors who accept assignment. Doctors and other health care providers who accept assignment cannot charge you more than the Medicare approved amount.
Medicare will cover these services more than once a year if your doctor says you need them for diagnostic purposes. If an exam is considered diagnostic, Medicare covers 80 percent of the cost and the patient or their supplemental insurance is responsible for the other 20 percent.
For a complete list of Medicare preventive screenings go to Medicareinteractive.org preventive screening page.
Medicare Advantage plans now follow the Medicare preventive screening rules. Before 2011, when Medicare expanded its preventive screening list, Medicare Advantage plans used to say they covered more than Medicare.
This year my doctor’s office told me some Advantage plans are not covering lab work that would have been covered in the past as part of an annual physical. I suppose this is because the Advantage plans are going by, for example, the 5-year rule for cholesterol screening for people without cardiac problems. This seems to be confusing for both doctors and patients.
I just received a Medicare press release with the following information:
In Arizona, 274,735 people with traditional Medicare took advantage of at least one free preventive service in the first six months of 2013. Nationally 16.5 million people with Medicare have taken advantage of at least one free preventive service in the first six months of 2013.