| Test/Screen | Medicare Part B Coverage Eligibility |
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| Preventive visit | “Welcome to Medicare” preventive visit is available for Medicare coverage within the first 12 months of obtaining Medicare Part B.
- Measurement of height, weight, and blood pressure.
- Calculation of BMI.
- Simple vision test.
- Review of potential risk for depression and level of safety.
- Offer to talk about creating advance directives.
- Written plan on which screening, shots, and other preventive services needed.
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| Yearly “Wellness” visits | Annual “Wellness” visits for Medicare patients with Part B for longer than 12 months. The “Wellness” visits are used to develop or update a personalized prevention plan to prevent disease and disability based on current health and risk factors.
- Complete an HRA.
- Review medical and family history.
- Develop or update the list of current providers and prescriptions.
- Measure height, weight, blood pressure, and other routine measurements.
- Evaluate cognitive impairment.
- Personalize health advice.
- List risk factors and treatment options.
- Develop screening schedule for appropriate preventive services.
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| AAA screening | One-time AAA ultrasound if patient meets eligibility requirements. A referral is required. Risk factors for eligibility:
- Family history of AAA.
- Male age 65–75 years and have smoked at least 100 cigarettes/lifetime.
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| Bone mass measurement | Covered screen once every 24 months for people who meet the eligibility criteria:
- Women whose doctor determines both of these (based on medical history and other findings):
- Estro-deficient.
- At risk for osteoporosis.
- X-rays showing possible osteoporosis, osteopenia, or vertebral fractures.
- Person taking prednisone or steroid-type drugs or is planning to begin this treatment.
- Person who has been diagnosed with primary hyperparathyroidism.
- Person being monitored to evaluate the osteoporosis drug therapy is effective.
Covered more often if medically necessary. |
| Alcohol misuse screenings and counseling | Covered screen once per year for people who meet the eligibility criteria:
- Adults with Part B (including pregnant women).
- Use alcohol.
- Do not meet the medical criteria for alcohol dependence.
- Four brief face-to-face counseling sessions per year if these apply:
- Primary care doctor determines alcohol misuse.
- Competent and alert during counseling.
- Counseling must be provided:
- By a qualified primary care doctor or other primary care practitioner.
- In a primary care setting.
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| Cardiovascular disease (behavioral therapy) | One visit per year in PCP office or primary care clinic:
- Check blood pressure.
- Discuss aspirin use (if appropriate).
- Discuss dietary information.
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| Cardiovascular disease screening | Screening blood tests every 5 years:
- Cholesterol.
- Lipids.
- Triglycerides.
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| Cervical and vaginal cancer screenings | Part B covers Pap tests, pelvic exams, and clinical breast exams:
- Once every 24 months for all women.
- Once every 12 months if one of these apply:
- High risk for cervical or vaginal cancer.
- Childbearing age and have had an abnormal Pap test in past 36 months.
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| Colorectal screening | FOBT:
- Coverage with a referral from a physician, physician assistant, nurse practitioner, or clinical nurse specialist.
Multitarget stool DNA test:
- Covered once every 3 years if all conditions are met:
- 50–85 years of age.
- No signs or symptoms of colorectal disease including, but not limited to:
- Lower gastrointestinal pain.
- Blood in stool.
- Positive guaiac fecal occult blood test.
- Fecal immunochemical test.
- At average risk for developing colorectal cancer, meaning:
- No personal history of the following:
- Adenomatous polyps.
- Previous colorectal cancer.
- Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
- No family history of the following:
- Colorectal cancers or adenomatous polyps.
- Familial adenomatous polyposis.
- Hereditary nonpolyposis colorectal cancer.
Screening flexible sigmoidoscopy:
- Once every 48 months for most people 50 years or older.
- If not high risk, is covered 120 months after a previous screening colonoscopy.
Screening colonoscopy:
- Once every 24 months if at high risk for colorectal cancer.
- If not high risk, is covered once every 120 months, or 48 months after a previous flexible sigmoidoscopy.
A screening colonoscopy can become a diagnostic colonoscopy when:
- Results in the biopsy or removal of a lesion or growth.
- The biopsy or removal happens during the same visit as the screening colonoscopy.
Barium enema:
- When utilized instead of a flexible sigmoidoscopy or colonoscopy:
- Coverage every 48 months if 50 years or over.
- Coverage every 24 months and are at high risk for colorectal cancer.
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| Dental | Medicare does not cover routine dental care or dental procedures such as cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. |
| Depression screening | Medicare covers one depression screening per year. The screening must be done in a primary care setting that can provide follow-up treatment and/or referrals. |
| Diabetes screening | Medicare covers screening to test for diabetes:
- Based on the screening test, may be eligible for two diabetes screenings each year.
- Screenings covered if any of the following risk factors exist:
- Diagnosed with prediabetes.
- Hypertension.
- History of abnormal cholesterol and triglycerides.
- Obesity.
- History of high glucose.
- Covers these tests if two or more of these apply:
- Age 65 or older.
- Overweight.
- Family history of diabetes (parents, brothers, sisters).
- History of gestational diabetes or the delivery of a baby weighing more than 9 pounds.
If covered with Medicare Part B and have prediabetes, may qualify for diabetes prevention program services to help make health behavior changes that can prevent or delay the onset of diabetes. The program begins with at least 16 core sessions over a 6-month period, which are offered in a group setting. After the core sessions, additional monthly sessions in the diabetes prevention sessions include the following:
- Tips on how to get more exercise.
- Strategies for weight control.
- Support from people with similar goals and challenges.
- A lifestyle coach, specially trained in motivation.
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| Diabetes self-management training | Outpatient diabetes self-management training (DSMT) to teach coping and management of diabetes:
- May cover up to 10 hours of initial DSMT. This training may include 1 hour of individual training and 9 hours of group training.
- May also qualify for up to 2 hours of follow-up training each year if it takes place in a calendar year after the year of initial training.
- Training includes the following:
- Tips for eating healthy, being active, taking drugs, and reducing risks.
- Must have a written order from a doctor or other healthcare provider for certain people with Part B who are at risk for complications from diabetes.
- Some exceptions apply:
- Group sessions are not available or if the doctor or qualified nondoctor practitioner notes special needs that would be better met in individual training sessions.
- Living in a rural area, may get DSMT services from a practitioner, such as a registered dietitian in a different location through telehealth.
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| Hepatitis C screening test | Covers one hepatitis C screening test if a primary care doctor or practitioner orders it:
- Also covers yearly repeat screening for certain people at high risk who meet one of these conditions:
- High risk because they use or used illicit injection drugs.
- Had a blood transfusion before 1992:
- Born between 1945–1965.
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| HIV screening | Voluntary HIV screenings, one test once every 12 months:
- Covered for people who meet the criteria.
- 15–65 years old.
- Younger than 15 or older than 65, and at increased risk.
- Pregnant:
- Covered up to three times during a pregnancy.
- Interval testing during pregnancy is not defined by CMS.
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| Immunizations | Flu shot:
- Normally covers one flu shot per flu season given in the fall or winter.
HepB:
- People at high or medium risk for HepB:
- Some risk factors noted as increased risk defined by Medicare include hemophilia, ESRD, diabetes, healthcare workers that have frequent contact with blood or bodily fluids, and other factors that increase risk for HepB (check with doctor to see if at high or medium risk).
Pneumococcal shot:
- One pneumococcal shot to prevent infections.
- Part B also covers a different second shot if it is given 1 year (or later) after the first shot.
- Discuss with the doctor or other healthcare provider to evaluate need for one or both shots.
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| Lung cancer screening | A lung cancer screening with LDCT once per year for patients who meet all of the following conditions:
- Age 55–77.
- Asymptomatic (no signs or symptoms of lung cancer).
- Either a current smoker or have quit smoking within the last 15 years.
- Tobacco smoking of at least 30 “pack years” (an average of one pack a day for 30 years).
- Written order from their physician.
- Before the first lung cancer screening, an appointment needs to be scheduled to:
- Discuss the benefits and risks of lung cancer screening.
- Decide whether lung cancer screening is right for the patient.
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| Mammography (medical) | Screening mammogram once every 12 months (11 full months must have passed since the last screening).
Diagnostic mammogram when medically necessary:
- Women with Medicare 40 years of age or older are covered.
- Women with Medicare 35–39 years of age can get one baseline mammogram.
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| Nutrition therapy services | MNT services and certain related services:
- A registered dietitian or nutrition professional who meets certain requirements can provide these services.
- Only a doctor can refer for these services.
- MNT services may include the following:
- An initial nutrition and lifestyle assessment.
- Individual and/or group nutrition therapy services.
- Follow-up visits to check on progress managing diet.
- In a rural area, MNT may be provided through telehealth. A registered dietitian or other nutrition profession, in a different location, would provide the service.
- Medicare covers MNT as part of overall dialysis care if dialysis is done in a dialysis facility.
- Eligibility includes people with Part B who meet at least one of these conditions:
- Have diabetes.
- Have kidney disease.
- Have had a kidney transplant in the last 36 months.
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| Obesity screening and counseling | Medicare covers behavioral counseling for weight loss. Counseling may be covered if given in a primary care setting (such as a doctor’s office).
- The counseling is required in a primary care setting so that it can be coordinated with other care and a personalized prevention plan.
- All people with a BMI of 30 or more are covered.
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| Prostate cancer screening | All men older than 50 (beginning the day after their 50th birthday).
Digital rectal examination:
PSA test:
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| STIs screening and counseling | Screening for chlamydia, gonorrhea, syphilis, and HepB:
- Once every 12 months.
- At certain times during pregnancy.
Medicare also covers up to two individual 20- to 30-minute, face-to-face, high-intensity behavioral counseling sessions each year for sexually active adolescents and adults at increased risk for STIs if referred by a doctor. |
| Smoking and tobacco use cessation | Counseling for up to eight face-to-face visits in a 12-month period performed by a qualified doctor or other Medicare-recognized practitioner
Eligibility for counseling includes all people with Part B who use tobacco. |
| Vision | Medicare does not cover routine eye examinations for eyeglasses or contact lenses.
AMD testing is covered.
Vision screen for glaucoma:
- Glaucoma test every 12 months for people at high risk for glaucoma:
- Diabetes.
- Family history of glaucoma.
- African Americans and those 50 years or older.
- Hispanic Americans and those 65 years or older.
Vision screen for retinopathy:
- Yearly exam for diabetic retinopathy.
- People on Medicare who have diabetes.
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