As part of the Affordable Care Act, Medicare now covers annual wellness visits and will provide payment for the creation of a personalized prevention plan.  The wellness visit will include a health risk assessment to:

• Establish or update the individual’s medical and family history;
• Create a list of current providers and suppliers involved in providing medical care, including a list of prescriptions;
• Take measurements of height, weight, body mass index, blood pressure and other routine measurements; and
• Detect cognitive impairments.

During the wellness visit, the health professional will establish or update a screening schedule for the next 5-10 years, based on recommendations of the United States Preventive Services Task Force (USPSTF).  The recommendations of USPSTF are based on an individual’s age and health status.  The visit may include health education or preventive counseling services designed to reduce risk factors that have been identified during the visit.  Examples of such education and counseling services include those designed to promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

The wellness visit may be conducted by a physician or another practitioner whose services are recognized by Medicare.  Such practitioners include physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, clinical social workers, and clinical psychologists. Practitioners may also include health educators, registered dietitians, or nutrition professionals working under the supervision of a physician.

The services for which no cost-sharing (deductible and/or co-payment) will be charged are:

• Mammograms every 12 months for eligible beneficiaries age 40 and older;
• Colorectal cancer screening, including flexible sigmoidoscopy or colonoscopy (see below);
• Cervical cancer screening, including a Pap smear test and pelvic exam;
• Cholesterol and other cardiovascular screenings;
• Diabetes screening;
• Medical nutrition therapy to help people manage diabetes or kidney disease;
• Prostate cancer screening (for most codes);
• Annual flu shot, pneumonia vaccine, and the hepatitis B vaccine;
• Bone mass measurement;
• Abdominal aortic aneurysm screening to check for a bulging blood vessel;
• HIV screening for people who are at increased risk or who ask for the test.[6]

Cost-sharing is also eliminated for the wellness visit and personal prevention plan.

CMS (Centers for Medicare and Medicaid) indicates that the following preventive services covered by Medicare will continue to be subject to cost-sharing:

• Digital rectal examination furnished as a prostate cancer screening service;
• Glaucoma screening;
• Diabetes self-management training services;
• Barium enema furnished as a colorectal cancer screening.

Note that, for all services, current coverage policies continue to apply.  For example, Medicare only covers bone mass measurements once every two years for qualified high-risk individuals. Testing within that time frame for people who meet the eligibility criteria will not be subject to a deductible or co-payment.  Bone mass measurement will not be covered for someone who is not a high risk individual, however, regardless of the change in cost-sharing requirements.

Okay, I admit…my life is pretty dull….  this weekend I was reading the 2011 Medicare & You Handbook which is provided by Medicare.  I thought I would pass on a few of the tidbits that caught my attention.

If you are on Original Medicare (and not Medicare Advantage)…

*If you have a procedure as an outpatient, you will pay 20% of the doctor’s fee and 20% of the facility fee.

*Medicare pays for blood tests to detect conditions that might lead to a heart attack or stroke – but they only pay for them every five years!  These are tests for cholesterol levels, lipids, and triglycerides.

*In order for Medicare to pay for a stay in a skilled nursing facility you must spend at least three days in the hospital for a related illness or injury. The three days do not include the day you are discharged, so you need to spend three nights in the hospital.

*Starting this year, you pay nothing for most preventive services BUT you probably have to pay co-insurance for the office visit.

*Smoking cessation counseling is now considered a preventive service that is covered by Medicare even if you haven’t been diagnosed with an illness caused or complicated by tobacco use. Starting this year, you pay nothing for the counseling sessions.

A note about Medicare Advantage:  All of the services mentioned above are treated differently if you are enrolled in a Medicare Advantage plan.  Preventive services and getting an annual checkup have always been a major selling point for Medicare Advantage plans.  If you are enrolled in a Medicare Advantage plan  there is no minimum hospital stay if you need to spend time in a skilled nursing facility.

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would require most Medicare-participating providers to give Medicare beneficiaries written notice about their right to contact a Medicare Quality Improvement Organization (QIO) with concerns about the quality of care they receive under the Medicare program.

Under current rules,  only beneficiaries admitted to hospitals as inpatients are required to receive information about contacting their state QIO regarding quality of care issues. The recently proposed rule would require most providers and suppliers to inform beneficiaries of their right to complain to a QIO about quality of care, as well as how to contact their local QIO. In all, the following care settings are impacted by this proposal:

• Clinics, rehabilitation agencies, and public health agencies that provide outpatient physical therapy and speech-language-pathology services
• Comprehensive outpatient rehabilitation facilities
• Critical access hospitals
• Home health agencies
• Hospices
• Hospitals
• Long-term care facilities
• Ambulatory Surgical Centers
• Portable x-ray services
• Rural health clinics and Federally Qualified Health Centers

I notice that skilled nursing homes are not in this list. I have heard very similar complaints from several seniors who spent time in the same skilled nursing facility in Tucson. They all wanted to complain to someone.  I guess I can refer them to the information below so they can find out if anyone will take their complaints seriously.

Beneficiaries with questions or concerns about the quality of care they receive under Medicare can learn more about their rights by calling 1-800-MEDICARE or by reading Medicare’s fact sheet, “Quality of Care Concerns,” online at http://www.medicare.gov/Publications/Pubs/pdf/11362.pdf.