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Medicare is a government-funded health insurance program. It
covers people 65 or older, some people with disabilities, and people
with permanent kidney failure (end-stage renal disease requiring
dialysis or a kidney transplant).
Medicare pays for certain services for preventive health care
and to find disease early, which includes a "Welcome to Medicare"
physical exam. Medicare also covers the costs of some screening tests
for breast cancer, cervical cancer, colorectal cancer, and prostate
cancer.
For more detailed information on Medicare eligibility and
coverage, contact the Centers for Medicare & Medicaid Services
(CMS) at 1-800-MEDICARE (1-800-633-4227) or visit their Web site at: www.cms.hhs.gov.
The "Welcome to Medicare" physical exam
Medicare pays for one "Welcome to Medicare" preventive doctor
visit. You must have the exam in the first year you enroll and you do
not have to pay a deductible for it. This exam is intended to help you
stay as well as you can and reduce your risk of serious health problems
in the future. It includes a standard medical history and physical
exam, a review of your social history, a review of risk factors for
depression, a look at your ability to do things and your overall
safety. End-of-life planning may also be discussed, so that your doctor
can have an idea of what you want if you later become unable to speak
for yourself. Your doctor or nurse may talk to you about how to live a
healthy lifestyle, with exercise and a proper diet. And you may be
referred to other experts for teaching or counseling if needed. Your
doctor might also recommend certain tests to look for cancer, heart
disease, or other problems and will also make sure you are up to date
with your shots.
Quitting smoking
To qualify for a quitting smoking benefit, the person covered
under Medicare must have a condition that is worsened by smoking or
tobacco use. Some examples would be heart disease, cancer, stroke, lung
disease, osteoporosis (weak bones), hypertension (high blood pressure),
diabetes, cataracts, or macular degeneration (vision loss). Or you may
qualify if smoking or tobacco use is causing problems with the way your
body processes a drug used to treat another medical condition. Insulin
and certain drugs used to treat high blood pressure, blood clots, and
depression are some of the drugs affected by tobacco.
If your doctor prescribes them, Medicare will cover 2 types of
face-to-face counseling to help you quit using tobacco (called tobacco
cessation counseling):
- Intermediate counseling, which is 3 to 10 minutes per
session
- Intensive counseling, which is more than 10 minutes per
session
Medicare will cover 2 quit attempts per year. Each quit
attempt may include a maximum of 4 intermediate or intensive counseling
sessions. Medicare will cover up to 8 sessions in a 12-month period.
The health care provider and patient can choose between intermediate
and intensive counseling.
Medicare Part D may also cover some prescription drugs used to
help you stop smoking. Certain drugs may need to be pre-approved, and
you may have a restricted number of refills. You will need to check
with your Part D drug coverage provider for details of coverage for
each drug. Over-the-counter treatments, such as nicotine patches or
gum, are not covered.
Breast cancer
One screening mammogram every 12 months is covered for all
women with Medicare age 40 and older. You can also get one baseline
mammogram between ages 35 and 39. You pay 20% of the Medicare-approved
amount with no Part B deductible. Medicare also covers new digital
technologies for mammogram screenings. Medicare provides 80% coverage
for a clinical breast exam once every 24 months, without Part B
deductible.
At this time, Medicare's cancer screening coverage information
does not include MRI in addition to mammogram as a covered screening
method for women who are at high risk for breast cancer. If you and
your doctor agree that you are at high risk for breast cancer, you may
be able to find out more by talking with your doctor's billing service
about possible Medicare coverage for breast MRI.
Cervical cancer
Medicare covers one Pap smear and pelvic exam every 24 months
if you are at low risk for cervical cancer. If you are at high risk for
cervical cancer, you may have these tests every 12 months. You will pay
nothing for the Pap smear lab test. For collecting the Pap smear and
the pelvic exam, you pay 20% of the Medicare-approved amount with no
Part B deductible. As part of the pelvic exam, Medicare covers a
clinical breast exam to check for breast cancer.
You are at higher risk for cervical cancer if you:
- Have had fewer than 3 normal Pap test results in the past 7
years
- Have ever had cervical cancer
- Were ever infected with HPV (human papilloma virus)
- Have a history of a STD (sexually transmitted disease)
and/or HIV
- Started having sex before the age of 16
- Have had more than 5 sexual partners
- Had many full-term pregnancies
- Were exposed to DES (diethylstilbestrol, a hormone drug)
because your mother took it while she was pregnant with you
- Eat a diet that is low in fruits and vegetables
- Are overweight or obese
Colorectal cancer
Medicare covers colorectal screening tests in people 50 and
older to help find colorectal cancer and/or pre-cancerous polyps
(growths in the colon) so they can be removed before they turn into
cancer. Coverage for these tests depends on the person's risk for
colorectal cancer.
For people with Medicare aged 50 and older at average risk for
colorectal cancer, coverage includes any one of these options:
- Fecal occult blood test (FOBT) once every 12 months
- Flexible sigmoidoscopy once every 4 years
- Colonoscopy once every 10 years (but not within 4 years of
a flexible sigmoidoscopy)
- Barium enema once every 4 years (instead of colonoscopy or
flexible sigmoidoscopy)
For people with Medicare aged 50 and older at high risk for colon
cancer, Medicare pays for some tests at shorter intervals:
- Colonoscopy once every 2 years (with no minimum age listed)
- Barium enema once every 2 years (instead of colonoscopy or
flexible sigmoidoscopy)
You are thought to be at high
risk if one or more of these is true for you:
- A close relative (sibling, parent, or child) has had
colorectal cancer or a type of polyp that could become cancer (called
an adenomatous polyp)
- Anyone in your family has had FAP (familial adenomatous polyposis)
- Anyone in your family has had HNPCC (hereditary nonpolyposis
colorectal cancer)
- You have ever had adenomatous
polyps
- You have ever had colorectal cancer
- You have ever had inflammatory bowel disease, such as
Crohn's Disease and ulcerative colitis
You pay nothing for the fecal occult blood test, but you may
have to pay for the doctor visit. For all other screening tests, you
must pay the co-payment, but you do not have to pay a deductible for
colorectal cancer screening, even if you haven't yet met your
deductible for the year. If a screening test leads to a biopsy or
removal of a growth, the test is considered diagnostic rather than
screening and you must pay the deductible. For flexible sigmoidoscopy
or colonoscopy you pay 25% of the Medicare-approved amount if the test
is done in a hospital outpatient department.
As of 2009, Medicare's cancer screening coverage information
does not list virtual colonoscopy or stool DNA testing as covered
screening methods for colorectal cancer.
Prostate cancer
For men over age 50 with Medicare, one digital rectal exam
(DRE) and one prostate-specific antigen (PSA) blood test is covered
every 12 months. Medicare will cover these services more than once a
year if the doctor says you need them for diagnostic purposes. You pay
20% of the Medicare-approved amount for the DRE after the yearly Part B
deductible. You do not have to pay a co-pay or the Part B deductible
for the PSA test.
Additional resources
More information from your American Cancer
Society
We have selected some related information that may also be
helpful to you. These materials may be ordered from our toll-free
number, 1-800-227-2345.
- Taking Charge of Your Health -- for African Americans
No matter who you are, we can help. Contact us anytime, day or
night, for cancer-related information and support. Call us at 1-800-227-2345 or
visit www.cancer.org.
References
Centers for Medicare and Medicaid Services. Guide to Medicare's Preventive
Services. Accessed at:
www.medicare.gov/Publications/Pubs/pdf/10110.pdf on November 18, 2009.
Centers for Medicare and Medicaid Services. Medicare. Accessed
at: 2009.www.cms.hhs.gov/home/medicare.asp on November 18, 2009.
Last Medical Review: 12/16/2009
Last Revised: 12/16/2009
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