Medicare and Preventive Benefits Available to Beneficiaries
(9/3/07)- Many of us have noticed a bus touring the 48 states, and more than 120 cities that sought to increase the public's awareness of many of the free preventive benefits available to Medicare beneficiaries. According to a recent Centers for Medicare and Medicaid Services survey fewer than one in 10 beneficiaries are getting all the free screening and immunizations recommended by public health officials.
Until now, just 5% of Medicare spending has been for advertising preventive services, officials say. In increasing spending to make the public aware as to the preventive programs available, the CMS hopes to save money in the long run.
Since 2005, Medicare has paid for an initial "Welcome to Medicare" comprehensive examination for new beneficiaries. Medicare started to pay for ultrasound screenings for aortic aneurysms in at-risk-patients this year.
Over the past five years, the program also has added coverage for glaucoma screenings, medical-nutrition therapy, cardiovascular and diabetic screening, and smoking and tobacco cessation counseling.
The preventive program covers flu, pneumonia and hepatitis B vaccinations, mammograms; tests for cervical and prostate cancer; bone-density screenings; and training for diabetes self-management.
A checklist for preventive services available under Medicare can be found at MyMedicare.gov.
(6/2/06)- J&J announced that CMS officials had agreed to cover the company's artificial spinal disk Charite implanted in patients under the age of 60, if the agency's local medical directors approve the coverage. This decision thus reversed an earlier ruling from the agency in February.
The Charite disk is surgically inserted to replace a damaged disk between the vertebrae in the spine. The Swiss medical device maker Synthes has conditional FDA approval to sell a competing artificial disk, and Medtronic and Stryker Corporation are also working on their versions of the disk implants.
(3/5/06)- Medicare officials announced new regulations that would expand coverage for severely obese beneficiaries. To be eligible, a beneficiary must have tried other treatments without success, have at least one health condition related to obesity and a body mass index of 35 or more.
The medical facility where the procedure is performed must be one in which a high number of the procedures have been performed. The sites must meet the standards set by one of two professional groups, the American Society for Bariatric Surgery or the American College of Surgeons.
About 34 % of Americans are considered over weight, and 27% are considered obese. In 2004 Medicare covered about 8,000 weight-loss surgeries, mostly for disable people under the age of 65. The procedure can cost between $15,000 to $20,000.
(2/16/06)- The budget bill that was recently signed by President Bush allocated funds, starting in 2007, for the free screening test of new enrollees to Medicare who are considered to be at high risk for abdominal aortic aneurysms. Abdominal aneurysms are responsible for at least 15,000 U.S. deaths each year.
One of the groups considered to be at high risk is men who have smoked more than 100 cigarettes in their lifetime. Another high-risk group is men and women whose family history includes aortic aneurysms. The free test for aortic abdominal aneurysms does not include those who are already covered by Medicare, only the new enrollees starting in 2007.
The backers of the bill for the free coverage estimate that about 58,000 people would be covered by its provision for the free screening test.
For more information on this topic please see our article: "Aortic Abdominal Aneurysm" and also our article on Medicare
(8/10/05)- Medicare officials announced in the Federal Register that it would begin to pay hospitals that use the drug tPa from Genentech Inc. starting October 1 in connection with the treatment for strokes. Until now, Medicare has paid hospitals a flat rate of about $5,700 per case for acute stroke victims. The drug, formally called "tissue plasminogen activator" costs $2,000 or more for a typical dose.
Medicare will pay hospitals that use the drug about $6,000 more per case, since it is the only clot-dissolving drug that has been approved for acute strokes. The drug is used for "ischemic" stroke-that is, stroke caused by artery blockage. Hospitals generally need to spend more on diagnostic tests and other therapy when they use tPa.
The drug is used intravenously during the first three hours after a clot-caused stroke. It is estimated that there are abut 700,000 strokes annually in the U.S., of which about 80% are estimated as "ischemic" strokes.
(5/16/05)- Under a new ruling from the Centers for Medicaid and Medicare Services (CMS) Medicare beneficiaries who are willing to pay about $2,500 will be able to opt for a high-tech cornea replacement lens that also corrects loss of reading vision. Previously Medicare would only pay about $2,000 for a standard cataract surgery procedure, which included the lens and fees for the facility and the surgeon.
This policy change may be the first of several new rulings that will allow Medicare patients to receive the latest technological advances in medicine, if they are willing to pay an extra amount for same, above what Medicare normally covers. Under the old rule, eye surgeons could not charge Medicare patients for the difference between the cost of conventional cataract surgery and the new high-tech cataract lens surgery.
The new lens treats two distinct medical conditions at the same time. A cataract is usually an age-related cloudiness that occurs in the eye lens. This clouding process treatment part of the cataract surgery was covered under the old rules for Medicare patients, but the loss of close vision (presbyopia) which causes the need for reading glasses was not covered.
The new type lenses which have been approved by the FDA are made by Eyeonics Inc.(Crystalens), a closely held company from Aliso Viejo, CA., Alcon Inc. (ReStor) and the ReZoom lens from Advanced Medical Optics Inc. Representative Christopher Cox (Rep.-CA) was instrumental in effectuating the changed ruling from the CMS.
(3/31/05)-The CMS said it will pay for counseling aimed at helping seniors stop smoking and using other tobacco products. In order to be eligible for this benefit, a Medicare beneficiary must have an illness caused or complicated by tobacco use, such as cardiovascular disease, lung disease, weak bones, blood clots and cataracts.
Beneficiaries who take medications to treat diabetes, high blood pressure, blood clots, and depression are also eligible for counseling because tobacco use interferes with the effectiveness of many medications used to treat those conditions. Smoking cessation products will be covered as part of the new Medicare drug benefit starting in January 2006 if they are prescribed by a physician.. The CDC estimates that there are about 9.3% of Americans age 65 and older who still smoke cigarettes.
(3/25/05)-The federal government has expanded its reimbursement coverage for Medicare patients who get blockages in their majoy neck arteries cleared intravenously rather than through surgery. This process is known as carotid stenting. After a catheter is inserted in a leg artery and threaded up to an obstruction in eitherof the two carotid arteries in the neck, a balloon is inflated to clear the vessel and metal mesh stent is deployed to keep it propped open. Last September, Guidant Corp. became the first company approved to sell such devices.
(2/11/05)-The Centers or Medicare and Medicaid Services (CMS) has determined that the new Medicare drug benefit would generally pay for erectile dysfunction medications when they were prescribed as being medically necessary. Gary R. Karr, a spokesman for the CMS state, "In general, prescription drugs that are medially necessary and approved by the FDA have to be covered."
Representative Steve King (Rep.-Io.) said however that he would introduce legislation that would prohibit Medicare and Medicaid making payments for "lifestyle drugs." In December, Representative King and 16 other members of Congress sent a letter to health officials urging that the federal government not cover such medications.
In 1998, the Clinton administration told state Medicaid officials that they had to pay for medically approved uses of Viagra for erectile dysfunction. There were some states that refused to cover these drugs under their Medicaid programs.
(2/6/05)-CMS officials are expanding reimbursement of implantable cardiovascular defibrillators (ICDs) to a much larger group of people than previously covered by Medicare. This decision came as a result of data from a study called Sudden Cardiac Death in Heart Services (SCD-HeFT) which determined that the devices could help prevent death in moderate heart failure patients, or those who had not had cardiac arrest.
At the same time Medicare will establish a registry of patients who will receive the devices. Manufacturers of the devices and many physicians had originally opposed the registry, but Medicare agreed that physicians would not be required to explain why a particular device was being used. The National Institutes of Health, Medtronics (a defibrillator manufacturer) and Wyeth primarily funded the study.
ICDs can cost $30,000 or more for the most advanced models, and some medical analysts said that the cost could exceed $3 billion a year to Medicare. The decision covers both ischemic and non-ischemic heart failure. Ischemic hear failure refers to disease caused by blocked arteries while non-ischemic heart failure can be caused by other factors. The study found that both types could benefit from the defibrillators.
In addition, CMS expanded coverage to Class IV heart failure patients who meet all current CMS coverage requirements for a cardiac resynchroniazation therapy (CRT) device. These devices, made by all the big ICD manufacturers, treat heart failure as well as provide the traditional life-saving shock of an ICD.
The ruling will also mean coverage for patients with Class II and Class III heart failure with ejection fractions of up to 35%. An ejection fraction refers to the heart's ability to pump, with lower ejection fractions signaling sicker patients.
It is estimated that there are as many as 500,000 Medicare beneficiaries who may benefit as a result of this expansion of coverage under the system.
(1/7/05)- According to government estimates, 9.3% of people 65 and over smoke. About 300,000 Americans die from smoking-related diseases. Even people who have been smoking all their lives can significantly reduce their chances of premature death by giving up smoking. The government has estimated that as much as 10% of the Medicare budget of $14.2 billion is spent for health related problems caused or complicated by smoking.
Beginning in 2005, Medicare will cover the cost of counseling services for those 65 and older who want to quit smoking. Mark McClellan, administrator for the CMS said, "I especially want to urge smokers on Medicare who are just starting to experience heart problems or lung problems to take advantage of this new help."
(8/2004)-One of the little known benefits contained in the Prescription Drug Law passed on December 12, 2003 is a provision that Medicare would cover, beginning January 1, 2005 an initial comprehensive physical exam for all new Medicare beneficiaries. In addition free coverage would become available for all people already in the program who take tests for cholesterol and diabetes.
The new "welcome to Medicare physical" for new beneficiaries includes influenza and hepatitis B vaccines, mammograms, Pap smears and pelvic examinations and screening tests for prostate cancer, colon cancer, glaucoma and osteoporosis, among other conditions. Medicare will cover such services as part of 'an initial preventive physical exam" within 6 months of enrollment.
As part of the exam Medicare will also pay for an electrocardiogram; an assessment of a person's risk of depression; hearing and vision tests; and a review of a person's agility to perform activities like bathing, dressing, eating and getting in and out of bed. The government will also pay for education and counseling for any problems discovered in the exams.
Medicare will also pay for diabetes screening tests twice a year for people who are at high risk of contracting the disease. It will also pay for blood tests every five years to detect cardiovascular disease in people with no apparent symptoms, including analysis of total cholesterol, high density lipoprotein and triglicerydes.
A new policy handed down by the Department of Health and Human Services removes the phrase "Obesity itself cannot be considered an illness," from the Medicare Coverage Issues Manuel. This will allow scientists, clinicians and companies to submit proposals recommending that Medicare cover certain treatments.
These treatments could include surgical procedures, dietary counseling or cognitive-behavior therapies. Drug treatments for obesity were ruled out in the Medicare prescription drug law that was passed in December 2003. Eighteen percent of the Medicare population is obese, according to the American Obesity Association, a nonprofit advocacy group.
The Senate's Committee of Health, Education, Labor and Pensions approved a bill that would require all private health insurance plans in the United States to pay for screening tests to detect colon cancer in people who are 50 or older, or have a high risk of developing the disease. Senator Edward M. Kennedy (Dem.-Mass.) and Senator Jesse Helms (Rep.-NC) are the sponsors of the bill.
According to Senator Kennedy: " Overwhelming scientific evidence indicates that with early detection, we can save lives, and millions and millions of dollars." On the other side of the debate Senator Tim Hutchinson (Rep.-Ark.) stated: " Every time we increase the cost of health insurance, we throw people into the ranks of the uninsured."
Last year more than 56,000 Americans died of colorectal cancer, the second leading cause of cancer deaths, after lung cancer. The Bush administration has not taken a public position on the Kennedy-Helms bill.
Please keep in mind that Medicare does not cover health care when you travel outside the United States, except for some emergency situations in Mexico and Canada.
Ambulatory Blood Pressure Monitoring- For patients with "white coat hypertension" (for those people whose blood pressure becomes elevated by the mere thought of going to a doctor's office) the wearing of a "cuff" that records blood pressure readings over a 24-hour period of time.
Angioplasty of the Carotid Artery- The HHS announced that Medicare would cover angioplasty of the carotid artery with stent insertion under certain conditions. The stent must be furnished in accordance with a FDA approved protocol governing category B Investigational Device Exemption (IDE) trials.
Annual Eye Care- To detect glaucoma for people
who are at high risk to the disease, including those with
diabetes or a family history of glaucoma. Medicare has announced
a new benefit that can prevent many Americans from going blind.
People who are covered by Medicare Part B (medical insurance) are
eligible for glaucoma screenings once every 12 months. Glaucoma
is the leading cause of blindness for African-Americans and for
all adults older than 60. If untreated, glaucoma can cause
irreversible loss of vision.
It's estimated that about half of the people with glaucoma don't even know
they have this condition. To learn more, call 1-800-MEDICARE, or visit the
Medicare website. http://www.medicare.gov/
BLOOD GLUCOSE MONITORS, TEST STRIPS AND LANCETS FOR ALL DIABETICS - Medicare covers blood glucose monitors, test strips and lancets for beneficiaries with Type I or Type II diabetes, regardless of whether they are treated with insulin. Medicare also covers therapeutic shoes for people with diabetes. Effective April 1, 2002, all Medicare enrolled pharmacies and suppliers must submit claims for blood glucose monitor test strips. You can no longer send in claims for blood glucose monitor test strips yourself. Ask the pharmacy or supplier if it is enrolled in the Medicare program prior to purchasing your diabetic supplies.
Medicare pays for diabetes outpatient self management only if:
A physician certifies that you or your caregiver can be
trained to use the monitor.
You or your caregiver has completed training to self-monitor diabetes, and your monitor is one designed for home use. Medicare will pay for up to 100 test strips and 100 lancets every month for insulin-treated diabetics. Additional test strips and lancets will be covered if you have a medical need that is documented by your physician. Medicare will pay for up to 100 test strips and 100 lancets every 3 months for a beneficiary with non-insulin treated diabetes.
BONE MASS TESTS- Medicare will cover a bone mass test for those at risk for osteoporosis and other bone abnormalities. To be covered you must fall into one of the five categories listed below:
The bone mass test must be ordered in writing by a doctor, performed under the doctor's general supervision, and should be reasonable and necessary for the individual. It must be performed using equipment approved by the Food and Drug Administration for bone mass testing. Medicare will make payment for a bone mass test once 23 months have passed since the last one was given. You are responsible for any unmet Part B deductible and the 20% coinsurance amount.
COLORECTAL CANCER SCREENING - Medicare covers the following screening tests or procedures for the early detection of colorectal cancer:
You pay nothing for the fecal occult blood test. For all other tests, 20% of the Medicare-approved amount after the yearly Part B deductible. For the flexible sigmoidoscopy or colonsocopy, you pay 25% of the Medicare-approved amount if the test is done in an ambulatory surgical center or hospital outpatient department.
Continuous positive airway pressure devices- which are nose masks used to help control sleep apnea, a condition that causes some people to stop breathing for brief periods during sleep. Coverage will begin in April 2002.
DIABETIC OUTPATIENT SELF MANAGEMENT TRAINING- Medicare covers diabetes outpatient self-management training services when they are furnished by a certified provider who meets certain quality standards. A physician must certify that such services are needed. A comprehensive plan of care related to the diabetic's condition to ensure compliance is also required.
Emphysemia Lung Operations- Medicare will pay for lung operations for certain severe emphysema lung operation but certain criteria has been established in order to be eligible to be covered. The operation involves cutting away diseased parts of the lungs, and it costs about $60,000. The coverage will be for those who have severe emphysema in the upper lobes of their lungs, and those who have both severe disease elsewhere in the lungs and a poor ability to exercise. The risk of the operation would also have to be evaluated before allowing the Medicare beneficiary to undergo the operation. The operation will be covered only at certain accredited hospitals. The Centers for Medicare and Medicaid would designate which hospitals are accredited for the operation but so far none have been named.
FLU SHOTS and Pneumonia - All people with Medicare are eligible for flu shots (once every flu season) and pneumonia shots (you may only need one). There is no deductible or coinsurance. If your provider accepts assignment you pay nothing. If you belong to an HMO you must receive the flu shot and pneumonia shot from your HMO. Hepatitis B shots are covered only for persons at risk for Hepatitis B, such as those with end-stage renal disease of hemophilia. You must pay 20% of the Medicare-approved amount.
Foot Care-will be available to diabetes patients with peripheral neuropathy, a nerve condition that lessens their ability to feel pain, thus increasing the risk of foot ulcers. Later this year Medicare will cover two foot exams a year.
Glaucoma Screening-Medicare covers an annual (once every 12 months) dilated eye examination for all people with Medicare if they are at risk for glaucoma, including individuals who have diabetes.
MAMMOGRAPHY- Medicare pays for screening mammograms every 12 months for all women age 40 and over. For women age 35-39, Medicare will help pay for one baseline mammogram. The Part B deductible is waived for screening mammograms. You are responsible for the Part B 20% coinsurance amount
Nutrition Counseling Benefit- Effective January 1, 2002 a nutrition benefit will be available to more than 7 million people who have diabetes or kidney disease. The patient must have a referral from his/her treating physician who feels that a proper diet will be helpful in controlling or treating the illness. The government will then pay for a registered dietician or other nutrition professional to assess the patient's needs, provide counseling and develop a treatment plan to improve the patient's diet which in turn will be useful in dealing with the primary illness. The Department of Health and Human Services estimates that this will cost Medicare about $270 million in the first five years for such coverage. Of the 40 million people on Medicare it is estimated that about 6 million of the elderly have lost at least half of their kidney function, and would be prime candidates for such counseling.
Prostate Cancer Testing - Beginning January 1, 2000 annual prostate cancer screening will be covered for men over age 50. Covered procedures will include a digital rectal exam (once every 12 months) and a prostate-specific antigen (PSA) blood screening (once every 12 months). No coinsurance and no Part B deductible for the PSA test. Generally 20% of the Medicare-approved amount for the digital rectal exam after the yearly Part B deductible.
Reimbursement for Using Pain Management Specialists-Effective January 1, 2002, the government will establish a reimbursement code that doctors can use to identify themselves as specialists in pain management. The Medicare reimbursement code will encourage doctors to provide such treatment to patients with cancer, arthritis, sickle cell anemia, AIDS, and other diseases that cause severe pain.
Pap Screening - A screening pap smear and pelvic exam (including a breast exam) are covered once every 2 years, or annually for women at high risk for vaginal or cervical cancer. You pay nothing for the Pap smear lab test. For Pap smear collection, pelvic and breast exams, 20% of the Medicare approved amount (or a set copayment amount) with no Part B deductible. A physician's order is required for a screening pap smear.
Smoke Ceasing Counseling- The government will pay for the cost of smoke screening counseling for those who are on Medicare and Medicaid
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "Selecting a Nursing Home"
By Allan Rubin
updated September3, 2007
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