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Medicare & ACA/ObamaCare Preventative Care

#ACA / ObamaCare Preventative Care & Wellness Programs

The Texas ruling of March 30, 2023 (KFF Summary)  doesn’t count in CA.  Please don’t take blanket summaries & hype as gospel.  Read the sources links

California law that requires all health plans regulated by the State of California to cover the same necessary preventive services at no cost to the patient, consumers enrolled in plans offered through Covered California will continue to have access to these critical health care services without disruption.  Covered CA Email dated 4.6.2023 * Joint Statement * 

 

Here’s a Plain English List!  from Health Care.Gov and Blue Shield of preventative services you can get with NO DEDUCTIBLE.

However, if Preventive care is given during an Office Visit or as an outpatient or vice versa Covered CA  it might not be covered under the Preventative Care section of your policy   Check with your doctor. Preventative Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. Specimen Policy Page 92 

If one has history or symptoms, then it’s covered under the diagnostic benefit Page 74  Subject to Co-Pays & the Deductible.   Maintenance of a known problem, like those listed below as common risk factors,  is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles.  Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link.  Annual physicals may not be a benefit LA Times 8.2.2016

Health Care Reform hopes to save premium dollars as 20% of Employee Health Care Spending is on these common risk factors: health net pulse.com/

 

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#Medicare Preventive Services

“Welcome to Medicare” preventive visit
 
Medicare covers a one-time preventive visit within the first 12 months that you have Medicare Part B (Medical Insurance). This visit is called the “Welcome to Medicare” preventive visit. The visit is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy.
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What happens during the visit?
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During the visit, your doctor will:
 
 
• Record your medical and social history (like alcohol or tobacco use, your diet, and your activity level).
 
• Check your height, weight, and blood pressure.
 
• Calculate your body mass index (BMI).
 
• Give you a simple vision test.
 
• Review your potential risk for depression and your level of safety.
 
• Offer to talk with you about creating advance directives, legal documents that allow you to put in writing what kind of health care you would want if you were too ill to  speak for yourself.
 
 
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Depending on your general health and medical history, your doctor will give you advice on education, and counseling to help you prevent disease, improve your health, and stay well. Your doctor will also give you a written plan (like a checklist) letting you know what screenings, shots, and other preventive services you need.
 
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What should I bring to the visit?
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When you go to your “Welcome to Medicare” preventive visit, bring these items:
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• Your medical records, including immunization records (if you’re seeing a new doctor). Call your old doctor to get copies of your medical records.
• Your family health history. Try to learn as much as you can about your family’s health history before your appointment. Any information you can give your doctor can help determine if you’re at risk for certain diseases.
• A list of prescription and over-the-counter drugs that you currently take, how often you take them, and why.
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Who’s covered, and how often is it covered?
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This visit is only covered one time, and you must have the visit within the first 12 months you’re enrolled in Part B.
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Your costs if you have Original Medicare
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You pay nothing if your doctor accepts assignment.
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Yearly “Wellness” visit

 

If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update a personalized prevention plan based on your current health and risk factors. This includes:
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  • Health risk assessment (Your doctor or health professional will ask you to answer some questions before or during your visit, which is called a health risk assessment. Your responses to the questions will help you and your health professional get the most from your yearly “Wellness” visit.)
  • Review of medical and family history.
  • Develop or update a list of current providers and prescriptions.
  • Height, weight, blood pressure, and other routine measurements.
  • Detection of any cognitive impairment.
  • Personalized health advice.
  • A list of risk factors and treatment options for you.
  • A screening schedule (like a checklist) for appropriate preventive services.
  • Learn more than you ever wanted to know about HRA – Health Risk Assessments
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How often is it covered?
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Once every 12 months.
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Your costs if you have Original Medicare
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You pay nothing for this visit if your doctor accepts assignment.
 .
You don’t need to have had a “Welcome to Medicare” preventive visit before getting a yearly “Wellness” visit. If you do get the Welcome to Medicare” preventive visit during your first year with Part B, you’ll have to wait 12 months before you can get your first yearly “Wellness” visit Publication 10110  
 
 

NOT an Annual Physical Exam!

Medicare does not cover an annual physical exam – see 15 pages from Medicare to explain the difference.  “It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’”

An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure. CA Healthline.org *

 
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​Medicare #Preventative Services Publication  # 10110

Medicare Preventative Services

 

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your medicare benefits # 101116

 

#Mammogram coverage under Medicare

 

Breast cancer screening (mammograms)

Breast cancer is the most common non-skin cancer in women and the second leading cause of cancer death in women in the U. S. Every woman is at risk, and this risk increases with age. Breast cancer usually can be treated successfully when found early. Medicare covers screening mammograms and digital technologies to check for breast cancer before you or a doctor may be able to find it manually.

Who’s covered?

Women 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between 35–39.

How often is it covered?

Once every 12 months.

Your costs if you have Original Medicare

You pay nothing for the test if the doctor accepts assignment.

Am I at high risk for breast cancer?

Your risk of developing breast cancer increases if any of these are true:

• You had breast cancer in the past.

• You have a family history of breast cancer (like a mother, sister, daughter, or 2 or more close relatives who’ve had breast cancer).

• You had your first baby after age 30.

• You’ve never had a baby.

 

Other pages on our website dealing with cancer and how Insurance and Rx Prescription coverage might pay for it

 

 

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Medicare Coverage of #Cancer Treatment # 11931 

Medicare coverage of cancer

Preventative Care
Bone Density Osteoporosis 

Medicare covers bone mass measurements to see if you’re at risk for broken bones due to osteoporosis. Osteoporosis is a disease in which your bones become weak and brittle. In general, the lower your bone density, the higher your risk for a fracture.

Bone mass measurement results will help you and your doctor choose the best way to keep your bones strong..
 
Who’s covered?
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Bone mass measurements are covered for certain people with Medicare whose doctors say they’re at risk for osteoporosis, and who have one of these medical conditions:.
 
• A woman whose doctor or health care provider says she’s estrogen-deficient and at risk for osteoporosis, based on her medical history and other findings
• A person with vertebral abnormalities as demonstrated by an X-ray
• A person getting (or expecting to get) steroid treatments
• A person with hyperparathyroidism
• A person taking an osteoporosis drug.
 
How often is it covered?
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Once every 24 months (more often if medically necessary).
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Your costs if you have Original Medicare.
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You pay nothing for this test if the doctor accepts assignment.  Publication 10110 
 
 
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Costs if you have a Medicare Advantage Plan?
 
Just as an example – Blue Cross MediBlue Access PPO  EOC Evidence of Coverage
 
In network – No charge, but subject to the qualifying rules above. EOC Page 45
Out of Network – $1,250 annual deductible and you pay 40%

Resources & Links

MLN  Medicare Preventive Services  for Professionals

How often are Eye exams covered?

Medicare doesn’t cover routine eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses. Medicare Part B (Medical Insurance) covers some preventive and diagnostic eye exams:

by an eye doctor who’s legally allowed to do the test in your state.

Who’s eligible?

All people with Part B who have diabetes are covered.

Your costs in Original Medicare

You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Note

To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service. medicare.gov yearly-eye-exam

  • cms.gov/VisionServices_FactSheet
  • FAQs / Ask Us a Question
  • ICD billing codes
    • 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
    • 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
    • 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

Dental For #Everyone,
has an excellent  website with full brochures, Instant online quoting and enrollment

Dental for everyone free quote

VSP Vision Enroll ONLINE

 #nutrition & weight control 

I lost 20 pounds and 4″ off my waist in 2011 and while my gut might be a little bigger… in the years since, at least I fit into the smaller clothes.  Here’s some of the tips and suggestions I found helpful.

 

 

Food & Nutrition Calculators

The online dietary assessment provides information on your diet quality, related nutrition messages, and links to nutrient information. After providing a day’s worth of dietary information, you will receive an overall evaluation by comparing the amounts of food you ate to current nutritional guidance. To give you a better understanding of your diet over time, you can track what you eat up to a year.

Resources

Our other pages on Preventative & Wellness Benefits & Tips

Wellness and Prevention Programs from #Kaiser

 

Employers have an opportunity to improve the health of your employees every day. Making small changes to your workplace and company policies is a great way to start, and it’s where you can make the biggest impact. On these pages, you’ll find the tools and support to build a culture of health at work — and see how the right partner can help guide you along the way.

reduce absences caused by the flu set up on-site flu clinics. There’s a 6-week lead time to set up a clinic and clinics are available from mid-September to mid-December depending on your  location.

Benefits of Employee Wellness Programs for Small Business

6 Low-Cost Wellness Ideas for Small Businesses

More Kaiser Tools

 

Kaiser’s Website on why workforce health Matters

Kaiser's Website on why workforce health Matters

 

Mental Health

kaiser my strength
myStrength_for_Employers_Brochure
myStrength_Flyer_National
Calm_Promotional_Flyer

 

 

Controlling Presenteeism

 

It’s Monday morning, and all your employees are at their desks working—to some degree. Bill is having a mild asthma attack that’s making it hard for him to concentrate, Anne is dealing with depression, and Dana is still worn out from the flu. They’re at work, but not really all there. This is called “Presenteeism,” and we want to help you find a way to make sure your employees are at their best.

Quality Dividend CalculatorTM 2011, gives you a simple way to estimate how your choice of health plan will affect the productivity and absenteeism of your workforce.

When employees get higher quality care, they stay healthier, absenteeism drops, and productivity improves

Fewer Days Lost with Better Medical Coverage

Give yourself the winning edge with a customized online program from Kaiser Permanente in collaboration with Health Media®. You’ll get the clear steps and ongoing encouragement it takes to reach your health goals.

Presenteeism refers to attending work while ill. 

 
The development of interest in presenteeism, considers its various conceptualizations, and explains how presenteeism is typically measured.  Presenteeism has important implications for organizational theory and practice and the purchase of Employer Group Health Insurance.
 
Monday morning presenteeism

graph drain on productivity

why premiums are increasing

Insomnia – Proper Rest & Sleep

Get a Return on your Investment of your Health Insurance Premiums

 

Premiums are only 24 percent of your total health care costs. The other 76 percent are indirect costs associated with:

• Presenteeism—people showing up for work but not being as productive as they could be—63%

• Absenteeism and short-term disability—12%

• Long-term disability—1% For example, overweight and obese employees take more sick leave than nonobese employees and are twice as likely to have high-level absenteeism.

The average annual cost of medical expenses and absenteeism related to obesity can range from $460 to $2,500 per employee.

healthy.kaiserpermanente.org/flu 

Try this so your host or the waiter or host knows your full

Dining Etiquette Seminar – Eating Styles
See also Huff Post.com

Etiquette scholar.com 
dining I'm finished

Height & Weight Chart
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Height & Weight Chart

 

bmi visual graph

Child & Related Pages – Site Map 

Medi-Cal Share of Cost

If you are low income you might check out LIS – Low Income Subsidy – Extra Help to pay the Rx costs that are not covered.  LIS may also pay your Part D and Part B premiums and you might also qualify for Medi-Cal.

Part D Rx Low Income Subsidy – LIS – Extra Help

Misc Links & Resources

 

 

4 comments on “Preventative Care – Wellness Visit – Medicare”

    • Vitamin D Assay Testing: Medical Necessity and Documentation Requirements

      82306-Vitamin D, 25 HYDROXY, includes fraction(s), if performed

      Vitamin D lab assay is only reimbursable under Medicare when it meets the indications under the applicable LCD and not as a routine screening according to 42 CFR 410.32(a) source

      § 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

      (a) Ordering diagnostic tests. Except as otherwise provided in this section, all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary (see § 411.15(k)(1) of this chapter).

      Our webpage on Medicare Appeals

      Reply

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