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Medicare is a government-funded insurance program. It provides
coverage for people aged 65 or older, some people with disabilities,
and people with permanent kidney failure (end-stage renal disease
requiring dialysis or a kidney transplant).
Medicare provides 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 certain 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
Since 2005, Medicare coverage includes a one-time "Welcome to
Medicare" preventative physical exam. It must be done within the first
year of enrollment and you do not have to pay a deductible for it. This
exam is intended to help you reduce your risk of developing serious
health problems in the future. Along with doing a standard medical
history and physical exam, your doctor or nurse may talk to you about
how to live a healthy lifestyle, such as through exercise and a proper
diet. Your doctor may 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.
Quitting Smoking
To qualify for this benefit, the person covered under Medicare
must have a condition that is worsened by smoking or tobacco use, such
as heart disease, stroke, lung disease, weak bones, cataracts, or
multiple cancers. 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 those affected
by tobacco.
If your doctor prescribes them, Medicare will cover 2 types of
face-to-face 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. The total yearly benefit will cover up to 8 sessions in a
12-month period. The health care provider and patient can choose
between intermediate and intensive counseling.
In the original Medicare plan, you will pay 20% of the
Medicare-approved amount after you meet the yearly Part B deductible.
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 generally not covered.
Breast cancer
Mammogram screening is covered for all women with Medicare age
40 and older every 12 months. 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 provides coverage for a Pap smear and pelvic exam
once every 24 months. If you are at high risk for cervical or vaginal
cancer, you may have these tests every 12 months. You will pay nothing
for the Pap smear lab test. For Pap smear collection and pelvic exams,
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 or vaginal cancer
if you have had:
- an abnormal Pap test in the past 3 years
- cervical cancer in the past
- a history of sexually transmitted infections, including HPV
or HIV
- sex before the age of 16
- many sexual partners
- many full-term pregnancies
- exposure to DES (diethylstilbestrol, a hormone drug) before
you were born because your mother took it while she was pregnant with
you.
Colorectal cancer
Medicare covers colorectal screening tests to help find
pre-cancerous polyps (growths in the colon) so they can be removed
before they turn into cancer.
For people with Medicare aged 50 and older at average risk of
colorectal cancer, coverage includes:
- fecal occult blood test (FOBT) 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
specified)
- barium enema once every 2 years (instead of colonoscopy or
flexible sigmoidoscopy)
The risk for colorectal cancer increases if you or a close
relative have had colorectal cancer, if you have had colorectal polyps,
or if you have inflammatory bowel disease (like ulcerative colitis or
Crohn's disease).
You pay nothing for the fecal occult blood test, although you
may have to pay for the doctor visit. For the barium enema, you pay 20%
of the Medicare-approved amount. 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 2007, you do not have
to pay a deductible for colorectal cancer screening, even if you
haven't yet met your deductible for the year. You will still need to
pay co-insurance (20% or 25% as noted above) for the barium enema,
colonoscopy, or flexible sigmoidoscopy.
As of mid-2008, 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, coverage is provided for a
digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood
test every 12 months. Medicare will cover these services more than once
a year if the doctor says you need them for diagnostic purposes.
Generally, you pay 20% of the Medicare-approved amount for the digital
rectal exam after the yearly Part B deductible. You pay no co-insurance
and no 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-ACS-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-ACS-2345 (1-800-227-2345) or
visit www.cancer.org.
References
Centers for Medicare and Medicaid Services. Guide to
Medicare's Preventive Services. Available at:
www.medicare.gov/Publications/Pubs/pdf/10110.pdf. Accessed April 30,
2008.
Medicare Preventive Services. Smoking Cessation (Counseling to
Quit Smoking.) Available online at:
www.medicare.gov/health/smoking.asp. Accessed May 2, 2008.
Personal Communication: Representatives at 1-800-MEDICAR, May
1 and 2, 2008.
Last Medical Review: 10/31/2008
Last Revised: 10/31/2008
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