Medicare Coverage for Cancer Prevention and Early Detection
What is Medicare?
Medicare is a government-funded health insurance program. It covers people age 65 or older and some younger people with disabilities. Since the Affordable Care Act passed in 2010, certain prevention and early detection services might cost Medicare recipients nothing.
Medicare pays for certain preventive health care services and some of the tests used to help find diseases early – early detection tests. It also covers a “Welcome to Medicare” physical exam and a yearly “Wellness exam.”
Medicare coverage for tests and services related to cancer prevention and early detection are outlined here. Please call us toll-free at 1-800-227-2345, or visit our website, www.cancer.org, if you would like to learn more about the American Cancer Society recommendations for cancer prevention and early detection.
The Medicare parts
There are several parts to Medicare.
- Part A covers most hospitalization and inpatient expenses. It also covers skilled nursing facility care, hospice care, and home health care.
- Part B covers medically needed care such as doctor visits, outpatient care, home health care, medical equipment, some services to prevent disease, and certain tests used to help find diseases early.
- Part C refers to the optional Medicare Advantage Plans offered by private companies approved by Medicare. If you choose one of these plans, it will provide all of your Part A and Part B coverage. Most include Part D coverage, too. Medicare Advantage Plans may also offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs.
- Part D covers prescription drugs, and you must choose a Medicare Prescription Drug Plan for it. Most Medicare Advantage plans cover prescription drugs, but if yours doesn’t, you may still choose a Prescription Drug Plan.
Does the doctor take Medicare and accept assignment?
Before you schedule any appointments or tests, be sure that the doctor accepts Medicare, and find out whether he or she “accepts assignment.” A doctor who accepts assignment is called a participating doctor, and will:
· Take the amount Medicare pays, along with your standard deductible and co-pay, as payment in full.
· Usually wait for Medicare to pay for their share before asking for your payment.
· Likely cost you less in “out-of-pocket” charges (the amount you must pay).
· Send your claims to Medicare and not charge you for submitting the claim.
· Not require you to pay a deductible and co-pay for many preventive services. (These are discussed below.)
Non-participating doctors don’t routinely take assignment. If your doctor doesn’t accept assignment for all Medicare-covered services, you often have to pay out of pocket, and you can be charged more than Medicare covers. Medicare will pay you back part of the bill for the services they cover.
Opt-out doctors have opted out of Medicare entirely and will ask you to sign a private contract explaining that Medicare won’t pay anything to you or the doctor. You’re responsible for all charges if you see these doctors.
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 website at www.medicare.gov.
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. But 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 might want to ask how much you’ll have to pay before you have anything done.
Why do it? This visit is intended to help you stay as well as you can and look at ways you may be able to reduce your risk of serious health problems in the future. It includes questions about your past and current health, surgeries, medical problems, drinking and smoking habits/history, and risk factors for things like depression and diabetes.
Before you go: To get the most from your visit, make a list of all surgeries, medical problems, treatments, hospital stays, injuries, allergies, and vaccines you’ve had, especially if you’re seeing a new doctor. Make another list of all the medicines, vitamins, and supplements you use, including the doses and how often you take them. Ask relatives about illnesses that “run in the family” (medical problems your parents, children, and siblings have had) and take that information with you. And finally, bring a list of all the other doctors who are involved in your health care.
What’s the visit like? The Welcome visit includes a physical exam, a look at your ability to do everyday things, and your overall safety. The doctor or nurse might talk to you about living a healthier life with exercise and a healthy diet. 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.
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 make sure you are up to date with your shots (vaccines). You might want to ask if these referrals and other tests are covered by Medicare and how much it will cost you to have them.
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 discussed above. Remember to update your medicine list and doctors’ names, and let the doctor know about any changes in your family health history. If your doctor accepts assignment, you don’t have to pay for these yearly visits unless other tests or services are done. Again, referrals and other tests may not be fully covered by Medicare, so you may want to ask how much it will cost you to have them.
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.
For all of the preventive services listed below, keep in mind that you may have a co-pay for the office visit when you get the services unless you’re there for your “Welcome” or “Wellness” visit.
Medicare coverage for quitting tobacco
Medicare offers help for quitting tobacco, called tobacco-use cessation counseling.
If you have a condition that’s been caused or made worse by smoking or tobacco use, or if you take a medicine that’s affected by tobacco, 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’re counseled in a hospital outpatient setting, you’ll also have to pay the hospital co-pay.
Conditions caused or worsened by tobacco use include heart disease, cancer, stroke, lung disease, osteoporosis (weak bones), hypertension (high blood pressure), diabetes, cataracts, macular degeneration (vision loss), and more.
Drugs affected by tobacco include insulin and certain drugs used to treat high blood pressure, blood clots, and depression.
If you do not have a condition that’s caused or worsened by tobacco use, Medicare covers tobacco-use cessation counseling as a preventive service. Medicare will pay for up to 8 face-to-face visits with an approved health provider in a 12-month period. You pay nothing as long as the doctor or other qualified health care provider accepts assignment.
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.
Medicare coverage for breast cancer screening
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 women at high risk and those 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 (magnetic resonance imaging) along with a mammogram as a 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 or breast MRI.
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.
Medicare coverage for cervical cancer testing
Medicare covers one Pap test and pelvic exam every 24 months if you are at average risk for cervical cancer. If you’re at high risk for cervical or vaginal 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.
As of 2015, Medicare’s cancer screening coverage information does not list HPV testing as a covered screening test for cervical cancer.
Talk to your doctor about your cervical cancer risk and the testing plan that’s best for you.
Medicare coverage for colorectal cancer testing
Medicare covers colorectal screening tests in people 50 and older to help find colon or rectal 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 a co-payment 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 then 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, or 4 years after a previous flexible sigmoidoscopy
- Barium enema once every 4 years (if done instead of colonoscopy or flexible sigmoidoscopy); you pay 20% of the Medicare-approved amount for the doctor’s services and a co-pay to the hospital if it’s done in a hospital outpatient setting
- Cologuard™ stool DNA test once every 3 years (as of October 2014, this is the only stool DNA test covered by Medicare)
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:
- Colonoscopy once every 2 years (with no minimum age listed)*
- Barium enema once every 2 years (if done instead of colonoscopy or flexible sigmoidoscopy), and you pay 20% of the Medicare-approved amount for the doctor’s services and a co-pay to the hospital if it’s done in a hospital outpatient setting
As of 2015, Medicare’s cancer screening coverage information does not list virtual colonoscopy as a covered screening method for colorectal cancer.
*Important note: If a colonoscopy leads to a biopsy or removal of a growth (polyp), the test is considered diagnostic, not screening. In this case you might have to pay 20% of the Medicare-approved amount for the doctor’s services, as well as co-pays in a hospital outpatient setting. In this situation, you should not have to pay the deductible. But this means that you may not know if you have a co-pay until after the test is done, and these costs can be over $1,000.00. You may want to talk to your doctor and the facility’s billing office about this beforehand.
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 ask your doctor if you fit that definition.
Medicare coverage for prostate cancer testing
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 50th 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 for the DRE. If the DRE is done in a hospital outpatient setting, you must pay the hospital co-pay, too.
Talk to your doctor about your prostate cancer risk and whether testing is right for you.
Medicare coverage for lung cancer testing
Medicare covers lung cancer screening with a low dose CT scan once per year if you have Medicare, are 55-77 years old, have a tobacco smoking history of at least 30 pack years*, and you either continue to smoke or you have quit smoking within the last 15 years.
You must get a written order from your doctor or other health care provider.
Coverage also includes a visit with your doctor (or other health provider) for counseling and shared decision-making on the benefits and risks of lung cancer screening.
The scan can only be done at imaging centers that meet certain criteria.
*A pack-year is the number of cigarette packs smoked each day multiplied by the number of years a person has smoked. Someone who smoked a pack of cigarettes per day for 30 years has a 30 pack-year smoking history, as does someone who smoked 2 packs a day for 10 years and then a pack a day for another 10 years.
To learn more
More information from your American Cancer Society
Here’s 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 website, 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 Prevention and Early Detection (also in Spanish)
Prostate Cancer Early Detection (also in Spanish)
Skin Cancer Prevention and Early Detection (also in Spanish)
Cancer facts and prevention
Taking Charge of Your Health (booklet) – for African Americans
Cancer Facts for Men (also in Spanish)
Cancer Facts for Women (also in Spanish)
Health Insurance and Financial Assistance for the Cancer Patient (also in Spanish)
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.
Centers for Medicare and Medicaid Services. Decision Memo for Screening for Colorectal Cancer – Stool DNA Testing (CAG-00440N). Accessed at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=277 on October 30, 2014.
Centers for Medicare and Medicaid Services. Medicare & You 2015. September 2014. Accessed at www.medicare.gov/pubs/pdf/10050.pdf on October 30, 2014.
Centers for Medicare and Medicaid Services. Your Guide to Medicare’s Preventive Services. February 2013. Accessed at www.medicare.gov/Pubs/pdf/10110.pdf on October 30, 2014.
US Department of Health and Human Services. Medicare Preventive Services. May 1, 2014. Accessed at www.hhs.gov/healthcare/prevention/seniors/medicare-preventive-services.html on October 30, 2014.
Last Revised: 02/11/2015