Preventive care is care you receive to prevent illness, detect medical conditions, and keep you healthy. Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. covers many preventive services, such as screenings, vaccines, and counseling. If you meet the eligibility requirements and guidelines for a preventive service, you must be allowed to receive the service. This is true for Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. and Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans. However, your plan’s coverage rules may apply.
- Original Medicare: You pay nothing (no
deductible
The deductible is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year.
or
coinsurance
The coinsurance is the portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of the approved amount or negotiated amount. In Original Medicare, the coinsurance is usually 20% of Medicare’s assignment.
) for most preventive services when you see a
participating provider
In Original Medicare, a participating provider is a health care provider who accepts Medicare and always takes assignment. They may not charge you more than Medicare’s approved amount. If you have Original Medicare and see a participating provider, you will pay a 20% coinsurance for Medicare-covered services. See also: Non-Participating Provider.
.
- Preventive services recommended by the U.S. Preventive Services Task Force are covered at 100% of the Medicare-approved amount (zero cost-sharing), but for other services you may be charged Original Medicare cost-sharing.
- You may be charged if you see a non-participating or opt-out provider.
- Medicare Advantage: When seeing an
in-network
In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers.
provider, you pay nothing for preventive services that are covered with zero cost-sharing by Original Medicare. This means that plans are required to cover your care without charging deductibles, copayments, or coinsurance, as long as you meet Medicare’s eligibility requirements for the service.
- Medicare Advantage Plans may charge you for preventive services that Original Medicare does not cover with zero cost-sharing.
- You may be charged if you see an out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. provider.
Under certain circumstances, you may be charged for services you receive related to your preventive service, even if the preventive service itself is covered at 100% of the cost. For example:
- During the course of your preventive care, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit. For example, if your doctor finds and removes a polyp during a colonoscopy, costs related to removing the polyp will apply.
- You may have to pay a facility fee depending on where you receive your preventive care. For example, certain hospitals charge separate facility fees when you receive a preventive service.
- You may be charged for a doctor’s visit if you meet with a doctor before or after receiving your preventive care.
Keep in mind that each preventive service has its own eligibility requirements and guidelines. Medicare may only cover a service a certain amount of times each year or under specific circumstances.
Note: Medicare may cover certain preventive services more frequently than guidelines suggest if they are needed to diagnose or treat an illness or condition.