Special CME Issue - West Virginia State Medical Association

Preventive Services for Older Adults: Recommendations
and Medicare Coverage
Todd H. Goldberg, MD, CMD, FACP
Associate Professor and Geriatrics Program Director,
Department of Internal Medicine, WVU Health Sciences
Center, Charleston Division & Charleston Area Medical
Center, Charleston
Introduction
In 1965, Medicare was originally
designed to cover acute illness and
short-term rehabilitation; routine
physicals and preventive screenings
were not covered at that time. The
Medicare law (42 USC 1935y, Sec.
1862) explicitly stated, and still
states categorically, that Medicare
unless specifically provided for,
does not cover items and services
“not reasonable and necessary for the
diagnosis or treatment of illness or
injury or to improve the functioning
of a malformed body member.” 1
Over the past 30 years, because
of the evolving importance and
acceptance of preventive medicine,
several exceptions providing
for specific preventive services
were subsequently added to the
covered benefits of Medicare Part
B for our senior outpatients (note:
unless otherwise specified all items
discussed in this article apply to
Medicare Part B outpatient coverage
only). Medicare first began covering
preventive services in 1981 with
the pneumococcal vaccination. The
Balanced Budget Act (BBA) of 1997 2
added cervical, breast, colorectal, and
prostate cancer screenings, diabetic
supplies, and osteoporosis screening.
The Medicare Modernization Act
(MMA) of 2003 3 further expanded
covered preventive services by
including the “Welcome to Medicare”
exam and cholesterol and diabetes
screenings. The Deficit Reduction Act
of 2005 added an aortic aneurysm
(AAA) screening benefit. 4 Most
recently, the Patient Protection
and Affordable Care Act of 2010
added an “Annual Wellness Visit”
under Medicare effective 2011. 5,6
Consequently Medicare now pays for
most commonly performed cancer
and other screenings in accordance
with the recommendations of the
American Cancer Society (ACS) 7
and US Preventive Services Task
Force (USPSTF, http://www.
uspreventiveservicestaskforce.
org/) and in fact is now mandated
to pay for all preventive services
rated “A” and “B” by the USPSTF
with no deductibles or coinsurance. 8
Most other commercial insurance
plans will also face the same
requirements, however this
discussion is limited to Medicareage
older adult patients (i.e. over
65). Each of the Medicare covered
preventive services, listed in Table 1,
will be discussed in some detail.
For additional information,
Medicare’s official “Medicare
Claims Processing Manual” Chapter
18 (www.cms.gov/manuals/
downloads/clm104c18.pdf) 5 and
other pages on Medicare’s web
site (www.medicare.gov) provide
the most current and complete
information on Medicare’s
benefits, guidelines and coverage
information for both providers
and the public/beneficiaries.
Cancer screenings
Cervical cancer screening, including
Pap smear and pelvic exam, has been
covered by Medicare since 1990. The
scheduleallows for an exam every 2
years for average-risk individuals.
High-risk women may receive a
Pap test and pelvic exam every 12
months. It should be noted that
current USPSTF guidelines suggest
discontinuing screening among
women aged 65 years or older who
have had adequate screening and
are not otherwise at high risk. 9
Breast cancer screening has been
covered by Medicare since 1991.
Mammography screening for breast
cancer is covered every 12 months
for women older than 40. A single
baseline examination is permitted
for beneficiaries aged 35 to 39. While
ACS and USPSTF recommend
mammography every 1-2 years after
Objectives
Upon completion of this article, the reader will be able to:
1) Counsel older adult patients on which preventive services are recommended by the U.S. Preventive Services Task Force and which
are covered by Medicare.
2) Individualize preventive care for elderly patients based on age, gender, individual risk factors and preferences.
3) Perform an Initial Preventive Physical Examination and Annual Wellness Visit including Medicare’s required components.
82 West Virginia Medical Journal