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Medicare FAQs

Why is CMS adding new preventive services as Medicare benefits?

Under Section 4105 of the Affordable Care Act, CMS may add coverage of “additional preventive services” through the National Coverage Determination (NCD) process if the service meets all of the following criteria. They must be:

  1. Reasonable and necessary for the prevention or early detection of illness or disability,
  2. Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF), and
  3. Appropriate for individuals entitled to benefits under Part A or enrolled under Part B of the Medicare Program.

Some services must be performed in a primary care setting – what is considered a primary care setting?

A primary care setting is one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Ambulatory Surgical Centers (ASCs), emergency departments, hospices, independent diagnostic testing facilities, inpatient hospital settings, Inpatient Rehabilitation Facilities (IRFs), and Skilled Nursing Facilities (SNFs) are not considered to be primary care settings under this definition.

How do I determine the last date a beneficiary received a preventive service, so that I know the beneficiary is eligible to receive the next service and the service will not be denied due to frequency edits?

Your options for accessing eligibility information depend on the Medicare Administrative Contractor (MAC) jurisdiction in which your practice or facility is located. For example, MACs who have Internet portals provide the information through the eligibility screens of the portals. You may also be able to access the information through the HIPAA Eligibility Transaction System (HETS), as well as HETS User Interface, through the provider call center Interactive Voice Responses (IVRs). CMS suggests that providers check with their MAC to see what options are available to check eligibility.

How can I help them remember when they are due for their next preventive service?

Medicare.gov provides a “Preventive Screening Checklist” for patients to use the checklist to track their preventive services. Click here to download the Preventive Screening Checklist.

Download the Quick Reference Chart  for more information or, visit cms.gov.

 

Other frequently asked Medicare questions are listed here on the medicare.gov site.