Medicare Preventive Services: Coverage and Costs

Key Takeaways:

  • Preventive services are designed to help improve health and detect disease early.
  • Medicare covers a wide range of preventive services, including cancer screenings, obesity, and substance abuse counseling, and screenings for other chronic conditions.

Preventive care services are health care services intended to promote your health and detect disease early. Preventive care seeks to discover conditions early when they are most treatable and curable and manage the disease so that complications can be avoided. It can help you to stay healthy and encourage good health habits, such as exercise, proper nutrition, keeping a healthy weight, and not smoking. Preventive care services can consist of exams, shots, lab tests, and screenings, as well as counseling, health monitoring, and health education to help you understand and promote your health and well-being.

Does Medicare cover preventive care services?

Yes, Medicare covers a defined set of preventive care services to promote the health and well-being of Medicare beneficiaries. Most of these services have been recommended by the U.S. Preventive Services Task Force and have no cost-sharing because of the Affordable Care Act. If a preventive care service is not on Medicare’s list of preventive care services, then you may have to pay the entire cost.  View the Medicare-covered Preventive Services list.

Can I get preventive care services if I have a Medicare Advantage plan?

Yes, preventive care services are covered under Medicare, regardless of whether you have Original Medicare or a Medicare Advantage plan. If you meet basic eligibility standards, you have the right to receive these services.

What is the difference between preventive services and diagnostic services?

A service is considered preventive if you have no prior symptoms of the disease. In some cases, Medicare only covers preventive care services if you have certain risk factors. On the other hand, diagnostic services tend to address symptoms or conditions that you already have. The classification of services as preventive versus diagnosis is important because it affects what you owe for them. You typically need to pay a copay, coinsurance, and/or deductible for diagnostic services.

Are preventive services free?

Usually, if you have Original Medicare, you have no coinsurance or deductible for certain Medicare preventive care services if you see a health care provider who accepts Medicare assignment. Doctors who accept assignments cannot charge you more than the Medicare-approved amount for services. If you have a Medicare Advantage plan, your plan cannot charge you for preventive care services that are free for people with Original Medicare as long as you see in-network providers. If you see providers that are not in your plan’s network, charges may typically apply.

Does Medicare cover an annual physical as a preventive care service?

No, rather than covering an annual physical, Medicare covers an initial Welcome to Medicare visit, and subsequent Annual Wellness visits to promote preventive care. These are not head-to-toe physical exams. Annual Wellness visits can only be done once in a 12-month period. You can still receive an annual physical from your primary care provider under Medicare, but charges typically apply as Medicare would not cover this “routine” service. It is not on the list of Medicare-approved preventive services.

Do I have to see a specific provider for preventive care services?

Yes, in general, for services to be covered by Medicare, you must see a provider that accepts Medicare. If you have Original Medicare, this means that you must see a Medicare participating provider, which is a provider who accepts Medicare assignments and participates in the Medicare program. If you have a Medicare Advantage plan, this means that you must see a provider that is in your plan’s network, which is a provider who accepts your Medicare Advantage plan as insurance. If you do not see a Medicare-participating provider or an in-network provider, charges typically apply to your preventive care service.

Know that for some preventive care services to be covered, Medicare requires that you receive them from a certain kind of provider, such as a primary care provider. The Medicare-covered Preventive Services list describes the preventive care services covered by Medicare and makes a note if Medicare requires that you receive the service from a certain kind of provider.