Preventive Care Under Medicare

Preventive care is care you receive to prevent illness, detect medical conditions, and keep you healthy. Medicare Part B covers many preventive services, such as screenings, vaccines, and counseling. If you meet the eligibility requirements and guidelines for a preventive service, you must be allowed to receive the service. This is true for Original Medicare and Medicare Advantage Plans. However, your plan’s coverage rules may apply.

• Original Medicare: You pay nothing (no deductible or coinsurance) for most preventive services when you see a participating provider.
  • Preventive services recommended by the U.S. Preventive Services Task Force are covered at 100% of the Medicare-approved amount (zero cost-sharing), but for other services you may be charged Original Medicare cost-sharing.
  • You may be charged if you see a non-participating or opt-out provider.
• Medicare Advantage: When seeing an in-network provider, you pay nothing for preventive services that are covered with zero cost-sharing by Original Medicare. This means that plans are required to cover your care without charging deductibles, copayments, or coinsurance, as long as you meet Medicare’s eligibility requirements for the service.
  • Medicare Advantage Plans may charge you for preventive services that Original Medicare does not cover with zero cost-sharing.
  • You may be charged if you see an out-of-network provider.

Under certain circumstances, you may be charged for services you receive related to your preventive service, even if the preventive service itself is covered at 100% of the cost. For example:

• During the course of your preventive care, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit. For example, if your doctor finds and removes a polyp during a colonoscopy, costs related to removing the polyp will apply.
• You may have to pay a facility fee depending on where you receive your preventive care. For example, certain hospitals charge separate facility fees when you receive a preventive service.
• You may be charged for a doctor’s visit if you meet with a doctor before or after receiving your preventive care.

Keep in mind that each preventive service has its own eligibility requirements and guidelines. Medicare may only cover a service a certain amount of times each year or under specific circumstances.

Note: Medicare may cover certain preventive services more frequently than guidelines suggest if they are needed to diagnose or treat an illness or condition.

© Medicare Rights Center. Used with permission.

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