Medicare Coverage for Cancer Prevention and Early Detection

Medicare is a government-funded health insurance program. It covers people age 65 or older and some younger people with disabilities.

Medicare pays for certain preventive health care services and some of the tests used to help find diseases early. It also covers a “Welcome to Medicare” physical exam and a yearly “Wellness exam.” Medicare coverage for tests and services that are related to cancer prevention and early detection are outlined here. Please call us toll-free at 1-800-227-2345, or visit our Web site, www.cancer.org, if you would like to learn more about cancer prevention and early detection.

There are several parts to Medicare.

• Part A covers most hospitalization and inpatient expenses.
• Part B covers medically needed care such as doctor visits, outpatient care, home care, some services to prevent disease, and certain tests used to help find diseases early.
• Part D covers prescription drugs.

Before you schedule any appointments or tests, you’ll want to be sure that the doctor accepts Medicare, and find out whether he or she “accepts assignment.” (A doctor who accepts assignment takes the amount Medicare pays, along with your standard deductible and co-pay, as payment in full. In the case of many preventive services, you don’t have to pay the deductible and co-pay. These are discussed below.)

For more detailed information on Medicare eligibility, costs, 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.gov and select “Medicare.”

The “Welcome to Medicare” visit

Medicare pays for one “Welcome to Medicare” preventive doctor visit. You must have this visit in the first year you enroll in Medicare Part B. If your doctor accepts assignment from Medicare, you pay nothing for this visit. However, if your doctor performs tests or other services that aren’t covered under the preventive benefit, you might have a co-pay, and the Part B deductible could apply. Be sure to ask if any recommended tests or procedures are covered. If they aren’t, you may want to ask how much you’ll have to pay before having anything done.

This visit is intended to help you stay as well as you can and look at ways to reduce your risk of serious health problems in the future. It includes questions about your past and current health, surgeries, medical problems, drinking, smoking, and risk factors for things like depression.

Make a list of all surgeries, medical problems, treatments, hospital stays, injuries, allergies, and vaccines you’ve had before you go — especially if you’re seeing a new doctor. To get the most from your visit, take another list of all the medicines, vitamins, and supplements you use, including the doses and how often you take them. Gather and take with you information about illnesses that “run in the family” (medical problems your parents, children, and siblings have had). And finally, bring a list of the other doctors who are involved in your health care.

The Welcome visit includes a physical exam, a look at your ability to do everyday 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.

The doctor or nurse might talk to you about how to live a healthier life, with exercise and a more nutritious diet. And you might be referred to other experts for teaching or counseling if needed. The 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 (vaccines).

The yearly “Wellness” visit

Once every 12 months you can have a wellness visit. This is very much like the “Welcome to Medicare” visit and can be a yearly follow-up to it. But you don’t need to have a “welcome” visit to have a “wellness” visit later. The wellness exam includes everything that the “Welcome to Medicare” visit covers, as listed above. Remember to update your medicine list and doctors’ names, and let the doctor know about any changes in family health problems. If your doctor accepts assignment, you do not have to pay for these yearly visits unless other tests or services are performed.

This visit is also a chance to review your cancer risks, talk about the tests you should have to look for cancer, and plan how often you should have them.

Quitting tobacco

Medicare will pay for counseling to help you quit using tobacco (called tobacco cessation counseling). It’s covered more fully if you don’t yet have any problems related to tobacco use. You pay nothing for this counseling if the health care provider accepts assignment, because it’s a preventive service. If you do have a health problem due to smoking or tobacco use, co-pays and deductibles may apply.

Medicare will help pay for counseling to quit tobacco if you 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). You might also qualify if smoking or using tobacco 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 counseling help for quitting because you’re having health problems, Medicare will help pay for up to 8 face-to-face visits with an approved health provider in a 12-month period. But you have to pay 20% of the Medicare-approved amount and any deductible that applies. If you get counseling in a hospital outpatient setting, you’ll also have to pay the hospital co-pay.

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 might have a limited number of refills. You’ll need to check with your Part D 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 fully covered for all women with Medicare age 40 and older. You can get one baseline mammogram between ages 35 and 39, too. Medicare also covers newer digital mammograms.

Medicare pays for a clinical breast exam (CBE) once every 24 months for women at average risk of breast cancer. A CBE is covered once every 12 months for those at high risk and women of child-bearing age who have had an exam that showed cancer or other changes in the past 3 years. (The CBE is usually done at the same time as your pelvic exam. See the “Cervical cancer” section below.) You pay nothing for these exams if the doctor accepts assignment.

At this time, Medicare’s cancer screening coverage information does not include MRI along with mammogram as a covered screening method for women who are at high risk for breast cancer. And if your mammogram shows a change that requires more pictures, you might have to pay the deductible and co-pay for a diagnostic mammogram.

Talk to your doctor about your breast cancer risk. If you and your doctor agree that you are at high risk, you may be able to find out more by talking with your doctor’s billing service about Medicare coverage for more frequent exams and breast MRI.

Cervical cancer

Medicare covers one Pap test and pelvic exam every 24 months if you are at average risk for cervical cancer. If you are at high risk for cervical cancer or are of childbearing age and have had an abnormal Pap test in the last 3 years, the tests are covered every 12 months.

You pay nothing for the Pap lab test or for collecting the Pap test and the pelvic exam, as long as your doctor accepts assignment from Medicare. As part of the pelvic exam, Medicare covers a clinical breast exam to check for breast cancer.

Talk to your doctor about your cervical cancer risk and the testing plan that is best for you.

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, when they had their last test, and whether something is found that needs to be removed during the test.

If you are age 50 and older with Medicare and are at average risk for colorectal cancer, any one of the listed tests is covered. You should not have to pay anything for the test. But keep in mind that you might have to pay a co-pay for the doctor’s services, anesthesia, or hospital visit. And coverage will be denied if your last test was too recent (for instance, you have a colonoscopy and have another one 9 years and 11 months later.)

• Fecal occult blood test (FOBT) once every 12 months
• Flexible sigmoidoscopy once every 4 years, or 10 years after a previous colonoscopy
• Colonoscopy once every 10 years, but not within 4 years of a flexible sigmoidoscopy
• Barium enema once every 4 years (if used instead of colonoscopy or flexible sigmoidoscopy); you pay 20% of the Medicare amount for the doctor’s services and a co-pay to the hospital if it’s done in a hospital outpatient setting

If you have Medicare, are age 50 and older, and are at high risk for colon cancer, Medicare pays for some tests at shorter intervals, such as these:

• Colonoscopy once every 2 years (with no minimum age listed)
• Barium enema once every 2 years (instead of colonoscopy or flexible sigmoidoscopy)

But, again, you may have to pay a co-pay or deductible for the doctor’s office or hospital visit.

Talk to your doctor about your colorectal cancer risk, the tests that are best for you, and how often you should be tested. Also be sure you understand if and how much it will cost you to have the tests that are planned. Keep in mind that Medicare covers people at high risk of colorectal cancer for more frequent testing at younger ages. Medicare has its own definition of what makes a person high risk, so talk with your doctor about whether you fit that definition.

Note that 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 co-pays to the doctor and hospital. In this situation, you should not have to pay the deductible. (This means that you may not know if you have a co-pay until after the test is done.)

As of 2013, 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 are covered every 12 months. This coverage starts the day after your 50^th birthday.

You pay nothing for the PSA test. But you must pay 20% of the Medicare-approved amount for the DRE, and the yearly Part B deductible applies.

To learn more

More information from your American Cancer Society

Here is more information you might find helpful. You also can order free copies of our documents from our toll-free number, 1-800-227-2345, or read them on our Web site, www.cancer.org.

Cancer early detection

American Cancer Society Guidelines for the Early Detection of Cancer (also in Spanish)

Breast Cancer: Early Detection (also in Spanish)

Cervical Cancer: Prevention and Early Detection (also in Spanish)

Colorectal Cancer Early Detection (also in Spanish)

Prostate Cancer: Early Detection (also in Spanish)

Cancer facts and prevention

Taking Charge of Your Health -- for African Americans

Cancer Facts for Men (also in Spanish)

Prevention Checklist for Men

Cancer Facts for Women (also in Spanish)

Prevention Checklist for Women

Health Insurance

Health Insurance and Financial Assistance for the Cancer Patient (also in Spanish)

Medicare Part D: Things People With Cancer May Want to Know

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. Medicare. Accessed at www.cms.gov/Medicare/Medicare.html on February 21, 2013.

Centers for Medicare and Medicaid Services. Medicare & You 2013. Accessed at www.medicare.gov/Publications/Pubs/pdf/10050.pdf on February 21, 2013.

Centers for Medicare and Medicaid Services. The Guide to Medicare Preventive Services, Fourth Ed. March 2011. Accessed at www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf on February 21, 2013.

Centers for Medicare and Medicaid Services. Your Guide to Medicare’s Preventive Services. May 2011. Accessed at http://www.medicare.gov/Publications/Pubs/pdf/10110.pdf on February 21, 2013.