Preventive care is care you receive to prevent illness, detect medical conditions, and keep you healthy. A service is considered preventive if you have no prior symptoms of the disease. In contrast, diagnostic services address symptoms or conditions that you already have.
First, let’s review how Medicare covers preventive services.
Medicare Part B covers many preventive services, such as screenings, vaccines, and counseling. To find out if Medicare covers your test, service, or item you can:
Contact your State Health Insurance Assistance Program (SHIP). Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Visit Medicare.gov’s page on Preventive and Screening Services
Consult your 2022 Medicare & You handbook
If you meet the eligibility requirements and guidelines for a preventive service, the service is covered whether you have Original Medicare or a Medicare Advantage Plan, although a plan’s network rules may apply. You should owe nothing for most preventive services so long as you see the right type of provider.
In some cases, you may be charged copays for services you receive related to your preventive service, even if Medicare pays for 100% of the cost of the preventive service itself. During your preventive visit, your provider may discover and need to investigate or treat a new or existing problem. This additional service may be diagnostic or involve treatment. Medicare covers diagnostic and treatment services differently than preventive services, and you may be charged coinsurances or copays.
You also may be responsible for paying a facility fee, depending on where you receive the service.
Next, let’s review the type of providers you should see.
You pay nothing for most preventive services if you see the right type of provider. If you have Original Medicare, you should receive preventive services from providers who accept assignment. These providers accept Medicare’s approved amount for a service as payment in full. For preventive services that Medicare covers at 100%, you owe no deductible or coinsurance when you see a provider who accepts assignment. And if you receive services that do have a cost, these providers cannot charge you more than the Medicare-approved deductible and coinsurance. If you are in a Medicare Advantage Plan, you should not be charged for preventive care services that are free for people with Original Medicare, as long as you see providers who are in-network for your plan.
If you see other types of providers, such as one who is out-of-network or one who does not accept assignment, then charges may apply to preventive care services that otherwise would have cost you nothing.
It helps to be prepared for your Welcome to Medicare and Annual Wellness Visits.
Medicare covers one Welcome to Medicare preventive visit in your first year of having Medicare Part B, then one Annual Wellness visit per year after that, with zero cost-sharing as long as you see the appropriate providers. Keep in mind that these visits are not head-to-toe physicals.
During the Welcome to Medicare Visit, your provider will:
Review your medical and social history as well as your health status and risk factors
Give you resources related to your risk factors and health needs
Give you a checklist or written plan with information about other preventive services you may need.
Annual Wellness Visits, which Medicare will cover once you have had Part B for 12 months, are yearly appointments with your primary care provider to create or update a personalized prevention plan. This plan can help prevent illness based on your current health and risk factors.
For both kinds of preventive visit, be prepared with information about your:
Medical history
Family history
Providers you see
Durable medical equipment you use
Medications you take.
Finally, take steps to detect inappropriate charges for your preventive care.
You can detect errors or fraudulent charges by carefully reviewing your health care statements from Medicare or your Medicare Advantage Plan. If you think you were charged for a preventive service and should not have been, contact your health care provider first. Claims summaries and medical bills can be confusing, so it is usually a good idea to ask your provider questions before reporting activity as potentially fraudulent. For example, you can call your doctor’s office and ask, “Why was I was billed this amount for this service?” Additionally, some providers are not familiar with the full list of Medicare-covered preventive services, and they may have made a simple mistake from their lack of knowledge about the benefits.
If you alert them to an error, the billing office should be able to correct it. If you still believe you have experienced potential fraud or have questions about it, you can contact your local Senior Medicare Patrol, or SMP. SMP counselors are trained to help you prevent, detect, and report health care fraud. You can call 877-808-2468 or visit www.smpresource.org to find your local SMP.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for questions about your Medicare costs and coverage and any Medicare problems that arise. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.)
Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).
Explore more blogs: