Who is CLAIM C ommunity L eaders A ssisting the I nsured of M issouri Part of the State Health Insurance Assistance Program SHIP a national network A statebased program to meet local needs of the Medicare population ID: 931874
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Slide1
Medicare Preventive Services
Slide2Who is CLAIM?
C
ommunity Leaders Assisting the Insured of MissouriPart of the State Health Insurance Assistance Program (SHIP), a national networkA state-based program to meet local needs of the Medicare population
Slide3Why SHIPs were Created
To help consumers:
understand Medicaremake informed decisions about benefitsresolve issues in navigating the Medicare programTo provide feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS)
Slide4Funding
Missouri Department of Commerce and Insurance (DCI) received the first federal grant in 1993
Primaris Foundation has been awarded the contract through DCI since 1993
Slide5Examples of Who We Serve
A Medicare beneficiary and their family
A social worker helping a clientA 64-year-old retiring in three monthsSomeone who just lost his/her benefitsA professional caregiver who needs informationA person who needs help enrolling in Part DSomeone needing help to pay healthcare costs
Slide6Medicare Preventive Services
Preventive services are designed to find health problem early, when treatment works best
Covered by Part B (Medical Insurance)Whether you get your coverage fromOriginal MedicareMedicare Advantage Plan
Slide7Medicare Preventive Services
In Original Medicare you:
Pay nothing for most preventive services if your provider accepts “assignment*” May pay more if provider doesn’t accept assignmentMay have a copaymentIf doctor performs other services not part of covered preventive benefits, orFor certain preventive services
Slide8Medicare Preventive Services
Assignment – is an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the Medicare-approved amount as full payment for covered services and not to bill you for anymore than the Medicare deductible and coinsurance.
Slide9List of Preventive Services
Abdominal
Aortic Aneurysm
Alcohol
Misuse
Bone Mass Measurement
Cardiovascular Disease
*
Cervical and Vaginal Cancer
Colorectal Cancer
Depression
Diabetes Screening
Diabetes Self-Management
Glaucoma Screening
Hepatitis C
HIV
Immunizations
Lung CancerMammogramsNutrition Therapy ServicesObesity screenings and CounselingWelcome to Medicare VisitProstate CancerSexually Transmitted Infections Tobacco Use Cessation Counseling Yearly Wellness Exam
*Cost is nothing if doctor or other qualified health care provider accepts assignment
Slide10Back
Abdominal
Aortic Aneurysms (AAA)*A one-time preventive ultrasound screening for abdominal aortic aneurysms (AAA). Ultrasound to detect weak area bulges in the aorta the largest artery in the body. Who is Covered?Beneficiaries who are at risk for AAA:
Family history of AAA and/or
Man - age 65-75 who has smoked at least 100 cigarettes (5 packs) in his lifetime
Slide11Alcohol
Misuse
Screening & Counseling*Back
Annual alcohol screening and up to four face-to-face counseling sessions. The screening must be done in a primary care setting that can provide follow-up treatment and referrals.
What is Covered?
Medicare beneficiaries, including pregnant women:
Who misuse alcohol
Whose levels of alcohol consumption do not meet criteria for alcohol dependence
Who are competent and alert at the time of counseling
If counseling is furnished by qualified primary care providers in a primary care setting
Slide12Back
Bone
Mass Measurement*Measures bone density to detect Osteoporosis. Covered once every 24 months or more often if medically necessaryWhat is Covered? Certain people at risk for losing bone mass:Woman who is estrogen–deficient and at risk due to medical history
Individuals with vertebral abnormalities
Individuals receiving (or expecting to receive) steroid therapy for more than 3 months
Individual with hyperparathyroidism
X-Rays show possible problems
Individuals being monitored to assess their response to FDA approved osteoporosis drug therapy
Slide13Back
Cardiovascular
Disease Risk Reduction Visit
One CVD face to face risk reduction visit per year includes
Encouraging aspirin use for the primary prevention of CVD when the benefits outweigh the risks
Screening for high blood pressure in adults 18 or older
Intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular- and diet-related chronic
disease
Must be conducted in the primary care setting.
Slide14Back
Cardiovascular Disease
Screening* Screenings Cardiovascular blood screening test – Once every five yearsTotal cholesterol testCholesterol test for high density lipoproteinsTriglycerides testWho is Covered?
All Medicare beneficiaries who have not been previously diagnosed with cardiovascular disease.
Slide15Back
Cervical
and Vaginal Cancer ScreeningPap test and pelvic exam with clinical breast examWho is Covered?Covered for all women
Once
every 24
months
Once
every 12 months, if you’re either
:
At
high risk for cervical or vaginal cancer
Of
childbearing age and had an abnormal Pap test in
past 36 months
Slide16Next
Colorectal
Cancer ScreeningScreeningsFecal Occult Blood Test – 12 monthsFlexible Sigmoidoscopy – 48 monthsColonoscopy – 24 monthsBarium Enema – Substitute for colonoscopy or sigmoidoscopyMulti-target stool DNA test (Cologuard™)
High Risk
Medicare
defines high risk of developing colorectal cancer as someone who has 1 or more of the following risk
factors:
Close relative (sibling, parent, or child) who has had colorectal cancer or polyps;
Family history of familial polyps;
Personal history of colorectal cancer;
Personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
Slide17Next
Screenings
Fecal Occult Blood TestNormal Risk: 12 months High Risk: 12 monthsFlexible SigmoidoscopyNormal Risk: 4 years or 10 years after a previous colonoscopy
High
Risk: 4 years
Colonoscopy
Normal
Risk: 10 years (generally) or 4 years after a previous flexible
sigmoidoscopy
High
Risk: 24 months (unless a screening flexible sigmoidoscopy is performed, then only every 4 years
Slide18Back
Screenings Cont.
Barium EnemaNormal Risk: 4 years when used instead of a sigmoidoscopy or colonoscopyHigh Risk: 24 months (as an alternative to a covered screening colonoscopy)
You pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment.
Multi-target Stool DNA test (Cologuard™)
Normal Risk:3 years
High Risk: 3 years
Slide19Back
Depression
ScreeningVarious screening tools are available. Choice of tool at discretion of clinician. The screening must be done in a primary care setting that can provide follow-up treatment and referrals. A limited number of visits.
Slide20Back
Diabetes
Screening*Diabetes screening test – Twice yearly (Calendar year) with certain risk factors or if pre-diabetic. If not at risk covered once yearly.Fasting plasma glucose testPost-glucose challenge testAny individuals with one of the following individual risk factors for diabetes is eligible for this
benefit
:
Hypertension, Dyslipidemia, Obesity BMI equal to or over 30
Previous identification of elevated impaired fasting glucose or glucose intolerance.
Or, an individual with two of the following risk factors for diabetes is also eligible for this new benefit:
Overweight (a body mass index greater than or equal to 25 km/m2)
A family history of diabetes
Age 65 years or older
A history of gestational diabetes mellitus or giving birth to a baby weighing > 9 lbs.
Slide21Back
Diabetes Self Management Training
Training for people with Diabetes to help them manage their condition and prevent complications. Instruction in self-monitoring blood glucoseEducation about diet and exerciseInsulin Treatment planWho is Covered?All people with Medicare who have diabetes.
Up to 10 hours a year
.
What Does the Beneficiary
P
ay?
20% of the Medicare-approved amount after Part B
deductible.
Co-payment
in a hospital outpatient setting
Slide22Back
Glaucoma
ScreeningGlaucoma is an eye disease caused by high pressure in the eye. It can develop gradually without warning and often without symptoms. Annual screening are a person’s best protection.Who is Covered? All persons determined to be high risk for glaucoma:Individuals with a family
history
Individuals
with
diabetes
African-Americans
, age 50 and
older
Hispanics
, age 65 and
older
What Does the Beneficiary Pay?
20% of the Medicare-approved amount after Part B deductible
Co-payment in a hospital outpatient setting
Slide23Back
Hepatitis
C Screening TestHepatitis C virus (HCV) is a serious disease (virus attacks the liver)Can cause chronic liver diseaseCirrhosis (scarring of the liver)Liver cancer, liver failure, and even deathWho is Covered?Covered when ordered by primary care practitioner in a primary care
setting.
Single, once-in-a-lifetime HCV screening test if born from 1945 to
1965.
Annually, if high-risk person with prior negative HCV screening
test.
Slide24HIV
Screening
Once a year or up to 3 times a year if pregnant. Who is Covered? Covered if you meet these conditions:If you are 15-65 and ask for the screening. You are younger than 15 or older than 65, at an increased risk for the virus, and ask for the screening. Back
Slide25Back
Lung
Cancer Screening* Medicare covers lung cancer screening with Low Dose Computed Tomography once per year for people with Medicare who meet all of Screening criteriaWho is Covered?Are age 55-77Are either a current smoker or have quit smoking within the last 15 yearsHave a tobacco smoking history of at least 30 “pack years”Get a written order from their doctor or qualified non-doctor
practitioner
Slide26Back
Breast
Cancer Screening (Mammogram)*Once every 12 monthsWho is Covered?All women with Medicare age 40 and older. One baseline mammogram is covered between ages 35-39
Slide27Back
Medical Nutrition Therapy
*Services can be given by a registered dietitian or Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Medicare covers 3 hours of one-on-one counseling services the first year, and 2 hours each year after that. Who is Covered? Certain people who have any of the following: Diabetes
Renal disease (people who have kidney disease, but aren’t on dialysis)
Had a kidney transplant within the last 3
years
A referral from doctor is required
Slide28Back
Obesity
Screening and Counseling*Intensive behavioral therapy includes:Screening for obesity using BMI measurementDietary (nutritional) assessmentIntensive behavioral counseling and therapyWho is Covered?People with Medicare who have a body mass index of 30kg/m
2
or
more
Slide29Back
One-Time
“Welcome to Medicare” Physical Examination*This physical examination is a once-a-lifetime benefit for a new beneficiary. Covers a physical exam ( blood pressure, height, and weight):simple vision check review of medical and social history, mental health screening,
functional ability and safety screening,
end of life planning and education on staying well
body mass index measurement
.
Who is Covered?
New Medicare beneficiaries and the exam must be done within 1 year of Part B coverage effective date
Slide30Back
Prostate Cancer
ScreeningScreenings Digital rectal exam – 12 monthsProstate Specific Antigen (PSA) Test – 12 monthsWho is Covered?All men with Medicare age 50 and olderWhat Does the Beneficiary Pay?20% of the approved amount for the digital rectal exam after the Part B deductible
Nothing for the PSA
Test
Slide31Back
Sexually
Transmitted Infections Screening and CounselingSexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. Covers up to 2 individual face-to-face high-intensity behavioral counseling sessions per year for sexually active adults at increased risk for STIs.
Who is Covered?
These screenings are covered for people with Medicare who are pregnant and/or for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider.
Medicare covers these tests once every 12 months or at certain times during pregnancy.
Medicare will only cover these counseling sessions if they’re provided by a primary care provider and take place in a primary care setting, like a doctor’s office
What the Beneficiary Pay?
Behavioral counseling sessions conducted in an inpatient setting, like a skilled nursing facility, won't be covered as a preventive service.
Slide32Back
Immunizations
Flu – Once a yearPneumonia – Varies with health statusHepatitis B – If at medium to high risk for hepatitisWho is Covered? Initial pneumococcal for all those that have not had the vaccine under Part B and will cover a different second vaccine 1 year after the first vaccine.
Slide33Back
Tobacco
Use Cessation Counseling*Counseling from a “qualified doctor or other Medicare-recognized practitioner” who can help them stop using tobacco. Coverage of 2 quit attempts per year. Who is Covered?Any person who uses tobacco
Must have a condition that is adversely affected by tobacco use or
The metabolism or dosing of a medication that is being used to treat a condition a person has is being adversely affected by the tobacco use
Medicare covers these counseling sessions as a preventive service if you haven’t been diagnosed with an illness caused by tobacco use
Slide34Back
Yearly
“Wellness” Exam*A yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This includes the following:Review of medical and family historyA list of current providers and prescriptionsHeight, weight, blood pressure, and other routine measurementsCreate a screening schedule for appropriate preventive services
A list of risk factors and treatment options for you
Screen for cognitive
issues
Who is Covered?
Anyone who has had Part B for longer than 12 months.
If you have had your “Welcome to Medicare” physical exam, you will have to wait 12 months before you can get your first yearly “Wellness” visit
Slide35myMedicare.gov
View claim status(excluding Part D claims)
Order a duplicate Medicare Summary Notice or replacement Medicare cardView eligibility, entitlement and preventive service infoView or modify your drug list & pharmacy infoView address of record with Medicare & Part B deductible status
Access online forms, publications & messages sent to you by CMS
Slide36Join Our Team!
Counselors
Leaders
in
Outreach
Administrative Support
Interest Specialists
Mentoring
AmeriCorps
Members
Slide37Thank You!
Slide38Contact Us:
1-800-390-3330 missouriclaim.org /m
/
missouriclaim
contact@missouriclaim.org