Preventive Services Under Medicare Advantage Plans

Preventative care services are important for everyone, especially seniors. The risk for health problems increases with age, and by preventing problems or identifying them early, seniors can enjoy longer, healthier lives. Some preventative services that are particularly important for older adults include annual wellness exams, influenza and pneumococcal vaccines, and screenings for diabetes, high blood pressure, cholesterol, osteoporosis and certain cancers.

Medicare Advantage plans provide coverage for preventative care services, though coverage details vary widely from one plan to another. Before enrolling in a plan, seniors should understand a plan’s preventative care coverage details, particularly if they are at an increased risk for developing conditions like high blood pressure or osteoporosis.

In this guide, we’ve outlined how Medicare Advantage plans work, how to know what a Medicare Advantage plan covers and some of seniors’ most frequently asked questions about their healthcare coverage through Medicare Advantage.

Medicare Advantage plans set the amounts they charge for services, premiums and deductibles on an annual basis. Enrollees automatically pay the Original Medicare Part B premium, which is $148.50 in 2021. Unlike Original Medicare, Medicare Advantage plans have yearly out-of-pocket limits for Part A and Part B covered services. Once an enrollee reaches their maximum out-of-pocket limit, they’ll pay nothing for covered services for the rest of the year.

Seniors may enroll in Medicare Advantage plans during the initial enrollment period, available when they turn 65, during the two annual enrollment periods or during the special enrollment period that opens if they lose coverage due to moving outside their current Medicare Advantage plan’s service area.

To be eligible for Medicare Advantage, seniors must:

• Be enrolled in or eligible for Original Medicare Parts A and B
• Live in their plan’s service area
• Be a U.S. citizen or legal resident for at least five consecutive years

Medicare Advantage plans cover all preventative services covered by Original Medicare, though unique coverage rules may apply. Preventative services covered include:

• One-time “Welcome to Medicare” preventive visit
• Annual wellness visits
• A one-time abdominal aortic aneurysm screening
• Vaccines
• Alcohol misuse screening and counseling
• Bone mass measurements once every 24 months for those at risk of osteoporosis
• Annual mammograms
• Cardiovascular disease screening and risk reduction counseling
• Cervical cancer screenings
• Prostate cancer screenings
• Obesity screening and counseling
• Depression screenings
• Diabetes screening and self-management training
• Glaucoma tests
• Medical nutrition therapy
• Hepatitis B and C infection screening
• Colon cancer screenings
• HIV screening
• Lung cancer screening
• Smoking and tobacco use cessation counseling

It’s important to note that many of these preventative services have their guidelines and eligibility requirements. For example, bone density screenings may only be covered at 100% for seniors who are at risk for osteoporosis.

Seniors who have Original Medicare receive these benefits with no cost-sharing obligations. For this reason, Medicare Advantage plans are required to cover preventive care services at 100%, as long as the enrollee sees an in-network healthcare provider. If the enrollee receives services from an out-of-network provider, charges typically apply, even if that provider accepts Medicare. Also, if diagnostic care is provided during a preventative visit, such as removing a polyp during a colonoscopy, charges may apply.

Medicare Advantage plans are not comprehensive. For example, while annual wellness visits are covered without cost-sharing obligations, annual physicals are not. If a service is not expressly listed in a plan’s “Evidence of Coverage” notice, then the senior should assume that it is not covered at 100%.

Yes, preventative services are covered under Medicare, regardless of whether the enrollee has Original Medicare or Medicare Advantage. Because of the Affordable Care Act, many preventive services are provided to Medicare beneficiaries with no cost-sharing.

In most cases, those with Original Medicare have no deductible or copay for preventive care services provided by a healthcare provider who accepts Medicare. Medicare Advantage plans cannot charge enrollees for preventive care services that are fully covered under Original Medicare unless the enrollee goes to an out-of-network healthcare provider.

To have preventative services covered, seniors with Medicare Advantage must receive them from an in-network primary care provider; going to an out-of-network provider or one who doesn’t accept Medicare will result in out-of-pocket charges. It’s important to note that even if a healthcare provider accepts the senior’s Medicare Advantage plan as insurance, that doesn’t necessarily mean that they are an in-network provider, and receiving services from them may result in higher charges. Seniors should check their plan’s list of in-network providers to confirm that their preferred provider is included.

While annual wellness visits are covered in full when provided by in-network healthcare providers, some diagnostic tests that are provided alongside routine care are not covered at 100%. Seniors should speak with their provider before receiving preventative care services to find out what services and potential costs they should expect.

Annual physicals are not covered under preventative care services. Annual wellness visits are covered, but these are not head-to-toe physicals. Instead, these visits include assessing functional and cognitive ability, evaluating risk factors for depression and providing health advice to promote wellness, such as weight loss or fall prevention.