Many people think Medicare only helps after they get sick or injured. But Medicare can also cover many preventive services. These are tests, visits, and vaccines meant to help find health problems early or help you stay healthy.
For people new to Medicare, preventive care can be one of the most useful parts of Part B. Still, it is important to understand that a service is not always free just because it sounds preventive. Your cost may depend on the type of visit, the provider, how often you receive the service, and whether Medicare considers it preventive or diagnostic.
What does Medicare mean by preventive care?
Preventive care is health care you receive before you have symptoms or a known health problem. It may include screenings for certain cancers, heart disease, diabetes, depression, and other conditions. It also includes certain vaccines and visits designed to review your health needs.
Original Medicare generally covers many preventive services through Part B. If you have a Medicare Advantage plan, the plan must cover at least the preventive services covered by Original Medicare, although the plan may have its own provider network and rules. Benefits, copays, and provider requirements may vary by plan and location.
When you use a provider who accepts Medicare assignment, many covered preventive services may have no Part B deductible or coinsurance. Assignment means the provider agrees to accept Medicare-approved payment as full payment for covered care. However, costs can apply when a visit or test changes from preventive care to diagnostic care.
What is the “Welcome to Medicare” visit?
If you are new to Part B, you may be eligible for a one-time preventive visit often called the “Welcome to Medicare” visit. You generally need to schedule it within your first 12 months after your Part B coverage begins.
This visit is not a full yearly physical. Instead, it is an opportunity to create a starting point for your health care. Your provider may review your medical history, current medications, height and weight, blood pressure, and possible health risks. The provider may also discuss recommended screenings, vaccines, and referrals.
Medicare may cover the visit at no cost when you meet the requirements and see a provider who accepts assignment. If your provider performs additional tests or treats a new problem during the same appointment, you may have costs for those additional services.
What is the Medicare Annual Wellness Visit?
After you have had Part B for more than 12 months, Medicare generally covers one Annual Wellness Visit every 12 months. This is different from the Welcome to Medicare visit and different from a routine physical exam.
During an Annual Wellness Visit, your provider may update your health history, review prescriptions, check for memory concerns or fall risks, discuss your care team, and help create a personal prevention plan. The goal is to identify risks and help you plan for future care.
Like the Welcome visit, this appointment may be covered with no out-of-pocket cost if the visit is handled as a preventive service and your provider accepts assignment. But you may owe a copay or coinsurance if the provider evaluates or treats a medical issue during that appointment.
Which screenings may Medicare cover?
Medicare covers many screenings, but the details can depend on your age, sex, risk factors, medical history, and how recently you had the test. Your doctor or health care provider can help you understand which screenings make sense for you.
Examples of preventive screenings Medicare may cover include:
- Blood pressure checks and cardiovascular disease screening
- Diabetes screening for people who meet certain risk criteria
- Colorectal cancer screening, such as certain stool tests or colonoscopies
- Breast cancer screening mammograms
- Cervical and vaginal cancer screenings for eligible people
- Lung cancer screening for people who meet age and smoking-history requirements
- Bone mass measurements for people at risk for osteoporosis
- Prostate cancer screening, including certain lab tests for eligible men
- Depression screening in an appropriate health care setting
- Hepatitis C and HIV screening for eligible people
Coverage rules and timing limits can change. For example, Medicare may cover one type of colorectal screening at a different interval than another. Ask the provider’s office whether the test is being billed as preventive and whether you meet Medicare’s coverage requirements.
Does Medicare cover vaccines?
Medicare can cover several important vaccines, but the part of Medicare that pays may differ. Many recommended adult vaccines are covered through Part D, whether you have a stand-alone Part D plan or a Medicare Advantage plan with prescription drug coverage.
Vaccines commonly covered under Part D may include shingles, RSV, Tdap or tetanus boosters, and others recommended for adults. Part B generally covers flu shots, COVID-19 vaccines, hepatitis B shots for eligible people, and certain vaccines needed after exposure or because of a medical condition.
With Part D, many recommended adult vaccines may be available with no cost sharing when they are covered and given through an in-network pharmacy or provider. Plan rules can vary, so it is wise to confirm coverage before receiving a vaccine.
Why might you get a bill for a preventive visit?
This is one of the most common Medicare surprises. A preventive service may begin as a no-cost screening, but it can become diagnostic if the provider finds a concern or investigates symptoms.
For example, a screening colonoscopy may lead to a biopsy or removal of a polyp. A wellness visit may include treatment for high blood pressure, joint pain, or another concern you bring up. Those added services may be billed separately and can create a deductible, copay, or coinsurance amount.
This does not mean the care was unnecessary. It simply means Medicare may use different billing rules for prevention and diagnosis. Before an appointment, consider asking the office: Is this being scheduled as a Medicare preventive service, and could there be charges if additional care is needed?
How can a Medicare Supplement help with preventive care costs?
A Medicare Supplement, also called Medigap, works alongside Original Medicare. It may help pay certain out-of-pocket costs left by Part A and Part B, such as deductibles, coinsurance, and copays, depending on the plan.
For a preventive service that Medicare covers in full, a supplement may not have much to pay. But if your visit becomes diagnostic or you need follow-up care, a Medicare Supplement may help with some of the remaining Medicare-approved costs. Coverage varies by plan letter, carrier, and state.
Preventive care is a helpful reason to stay connected with your doctor and understand your Medicare benefits. If you would like free, no-pressure help comparing Medicare Supplement options or understanding how they work with Original Medicare, you can reach out to Eric for guidance based on your needs.