The Affordable Care Act
(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
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
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.
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.
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.
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.
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
Colorectal cancer screening, including
flexible sigmoidoscopy or colonoscopy
Cervical cancer screening, including a Pap smear test and pelvic
Cholesterol and other cardiovascular screenings;
Medical nutrition therapy to help people manage diabetes or
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
HIV screening for people who are at increased risk or who ask
for the test.
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
Diabetes self-management training services;
Barium enema furnished as a colorectal cancer screening.
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.
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
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.
Protection and Affordable Care Act of 2010 (PPACA), Pub. L.
111-148 (March 23, 2010) §§4103, 4104.
 ACA § 4103
refers to practitioners described in 42 U.S.C.
 75 Fed. Reg.
40040, 40126 -40129 (July 13, 2010).
 42 U.S.C. §
 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.