Dear Marci,

I’d like to get screened for illnesses that I might be at risk for, but I’m confused about how Medicare payment works with preventive services. Can I get these services for free? How will I know if I’m covered?

-Lance (Missoula, MT)

Dear Lance,

Medicare, whether you have Original Medicare or a Medicare Advantage Plan, covers many preventive services at 100% for people who meet basic eligibility requirements. If you have Original Medicare, Part B will cover services recommended by the U.S. Preventive Services Task force with no deductible or coinsurance, as long as your doctor accepts assignment. If you have a Medicare Advantage Plan, you will have no cost-sharing for preventive care services that are free for people with Original Medicare, as long as you see an in-network provider.

Not every preventive service is covered at 100% for every Medicare beneficiary, though. In some cases, you may have to pay a coinsurance or copayment for your preventive service or related services.

Here are some things to keep in mind about Medicare coverage of preventive services:

• Some preventive services are covered under Part B, but have normal cost-sharing. This means that if you receive one of these services, you will be responsible for paying your deductible, as well as the 20% Part B coinsuranceor your Medicare Advantage Plan’s copay or coinsurance. These services include glaucoma screenings, diabetes self-management trainings, barium enemas, and digital rectal exams.
• Sometimes there are additional fees associated with visits for preventive services. For example, if the facility you go to has a separate facility fee, this will not be covered at 100%, meaning you will have to pay a coinsurance for the facility fee. Another example is if you see a doctor before or after you receive a preventive service. That visit is separate from the preventative service, and you will be responsible for the part of the cost of the visit that isn’t a preventive service.
• If your visit includes diagnostic or treatment related services, you will pay normal cost-sharing for those services. A service is considered preventive if you have no prior symptoms of the disease that the service is seeking to prevent, whereas a diagnostic service addresses symptoms or conditions that you already have. For example, if you go to the doctor for a colonoscopy (a preventive service), but your doctor finds or removes a polyp during the colonoscopy, the removal is diagnostic. You will be responsible for a deductible and/or a copay or coinsurance for the polyp removal. Similarly, if you go to your doctor for your Annual Wellness Visit (a preventive service), but your doctor treats a symptom you’re experiencing (a diagnostic service) during the same visit, you will be responsible for cost-sharing for services not related to the Annual Wellness Visit.
• You have to meet the eligibility standards for a screening, service, or item in order to have it covered with no cost-sharing. Speak with your doctor before you receive a service to make sure that you meet guidelines for gender, age, and certain risk factors.

Speak with your provider to find out which preventive services they believe you should have and to discuss your eligibility for them. To find out if Medicare covers your test, service, or item, you can click here or call 1-800-MEDICARE.

-Marci