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AFFORDABLE CARE ACT EXPANDS MEDICARE COVERAGE
FOR PREVENTION AND WELLNESS
 

The Affordable Care Act[1] (ACA) adds coverage for a new "Wellness Visit" and eliminates cost-sharing for almost all of the preventive services covered by Medicare, effective January 1, 2011.  This Alert discusses both provisions.

 

Wellness Visit

 

Starting next year, Medicare will cover a new annual wellness visit and will provide payment for the creation of a personalized prevention plan.  The wellness visit will include a health risk assessment to:

  • Establish or update the individual's medical and family history;

  • Create a list of current providers and suppliers involved in providing medical care, including a list of prescriptions;

  • Take measurements of height, weight, body mass index, blood pressure and other routine measurements; and

  • Detect cognitive impairments.

During the wellness visit, the health professional will establish or update a screening schedule for the next 5-10 years, based on recommendations of the United States Preventive Services Task Force (USPSTF).  The recommendations of USPSTF are based on an individual's age and health status.  The visit may include health education or preventive counseling services designed to reduce risk factors that have been identified during the visit.  Examples of such education and counseling services include those designed to promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

 

The wellness visit may be conducted by a physician or another practitioner whose services are recognized by Medicare.  Such practitioners include physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, clinical social workers, and clinical psychologists.[2]  Practitioners may also include health educators, registered dietitians, or nutrition professionals working under the supervision of a physician.

 

In proposed regulations to implement the new service, CMS listed "detection of any cognitive impairment" as one of the services to be included in the annual wellness visit.[3]  However, CMS did not recommend yearly screenings for depression or for functional impairments, based on the findings of the USPSTF. The USPSTF states that the optimal interval for screening for depression in older individuals is unknown, although it does recognize that recurrent screening may be needed for certain patients.

 

The new annual wellness visit builds upon the current "Welcome to Medicare" check-up or "initial physical examination" that is available to beneficiaries within 12 months of their becoming covered under Medicare Part B.  The initial preventive physical examination consists of a physical examination, including measurement of height, weight, and blood pressure and an electrocardiograph, with the goal of health promotion and disease detection.  The initial preventive physical examination also includes education, counseling, and referral with respect to screening and other preventive services, although it does not include clinical laboratory tests.[4]  A beneficiary is only entitled to a "Welcome to Medicare" check-up, and not a wellness visit exam, during the 12-month period after coverage begins under Part B.  However, a beneficiary is entitled to personalized prevention plan services once a year thereafter.

 

Elimination of Cost-sharing for Preventive Services

 

As indicated in a previous Alert, ACA has eliminated cost-sharing for most of the preventive services already covered under Medicare, effective January 1, 2011.[5]  The preventive services to which the provision applies are those that are appropriate for the individual and that are recommended with a grade of A or B by the USPSTF for any indication or population.  The services for which no cost-sharing (deductible and/or co-payment) will be charged are:

  • Mammograms every 12 months for eligible beneficiaries age 40 and older;

  • Colorectal cancer screening, including flexible sigmoidoscopy or colonoscopy (see below);

  • Cervical cancer screening, including a Pap smear test and pelvic exam;

  • Cholesterol and other cardiovascular screenings;

  • Diabetes screening;

  • Medical nutrition therapy to help people manage diabetes or kidney disease;

  • Prostate cancer screening (for most codes);

  • Annual flu shot, pneumonia vaccine, and the hepatitis B vaccine;

  • Bone mass measurement;

  • Abdominal aortic aneurysm screening to check for a bulging blood vessel;

  • HIV screening for people who are at increased risk or who ask for the test.[6]

Cost-sharing is also eliminated for the wellness visit and personal prevention plan.

 

CMS indicates that the following preventive services covered by Medicare are not recommended by USPSTF with a grade of A or B for any populations or indications, and will therefore continue to be subject to cost-sharing:

  • Digital rectal examination furnished as a prostate cancer screening service;

  • Glaucoma screening;

  • Diabetes self-management training services;

  • Barium enema furnished as a colorectal cancer screening.[7]

Note that, for all services, current coverage policies continue to apply.  For example, Medicare only covers bone mass measurements once every two years for qualified high-risk individuals.[8]  Testing within that time frame for people who meet the eligibility criteria will not be subject to a deductible or co-payment.  Bone mass measurement will not be covered for someone who is not a high risk individual, however, regardless of the change in cost-sharing requirements.

 

Clarification Concerning Smoking Cessation Counseling

 

Coverage for smoking cessation counseling services became effective for services provided on or after August 25, 2010, the date of the recent CMS memorandum. Services may be provided on both an outpatient and an inpatient basis, but they are reimbursed under Medicare Part B. Smoking cessation counseling services provided before January 1, 2011, are subject to cost-sharing.  Cost-sharing is eliminated for services provided after that date.

 


[1] Patient Protection and Affordable Care Act of 2010 (PPACA), Pub. L. 111-148 (March 23, 2010) 4103, 4104.

[2] ACA 4103 refers to practitioners described in 42 U.S.C. 1395u(b)(18)(C).

[3] 75 Fed. Reg. 40040, 40126 -40129 (July 13, 2010).

[4] 42 U.S.C. 1395x(ww).

[6] Fact Sheet:  Benefits for Seniors of New Affordable Care Act Rules on Expanding Prevention Coverage, http://www.healthcare.gov/news/factsheets/pdf/07-14-10_prevention_seniors_fact_sheet.pdf.

[7] 75 Fed. Reg. 40040, 40129-40136 (July 13, 2010).  The Federal Register includes a chart of the complete list of codes for preventive services that indicates whether the services are subject to cost-sharing both currently and starting in 2011.

[8] 42 U.S.C. 1395x

 
 


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