1. MO-2015-130-CLAIM August 2015 This material has been created or produced by CLAIM with financial assistance, in whole or part, through a grant from the Administration for Community Living. Funding is administered through the Missouri Department of Insurance Financial Institutions and Professional Registration and service is provided by the Primaris Foundation, a non-profit organization. Medicare Preventive Services CLAIM Missouri’s State Health Insurance Assistance Program

2. What is CLAIM? Community Leaders Assisting the Insured of Missouri Part of the State Health Insurance Assistance Program (SHIP), a national network A state-based program to meet local needs of the Medicare population

3. Why SHIPs were Created 1.To help consumers: understand Medicare make informed decisions about benefits resolve issues in navigating the Medicare program 2.To provide feedback on state and local problems to the Centers for Medicare & Medicaid Services (CMS) SHIPS were created in 1990 as part of the Medigap reform package

4. Funding Missouri Department of Insurance Financial Institutions & Professional Registration (DIFP) received the first federal grant in 1993 Primaris has been awarded the contract through the DIFP since 1993 Primaris Foundation is a non profit organization.

5. Examples of Who We Serve A Medicare beneficiary and her family A social worker helping a very sick client A 64-year-old retiring in three months Someone who just lost his benefits A professional caregiver who needs information A person who needs help enrolling in Part D Someone needing help to pay healthcare costs

6. Medicare Preventive Services Preventive services are designed to find health problem early, when treatment works best Covered by Part B (Medical Insurance) Whether you get your coverage from Original Medicare Medicare Advantage Plan

7. Medicare Preventive Services In Original Medicare you Pay nothing for most preventive services if your provider accepts “assignment*” May pay more if provider doesn’t accept assignment May have a copayment If doctor performs other services not part of covered preventive benefits, or For certain preventive services

8. Medicare Preventive Services Assignment – is an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the Medicare-approved amount as full payment for covered services and not to bill you for anymore than the Medicare deductible and coinsurance.

9. Alcohol Misuse Screening & Counseling Annual alcohol screening and Up to four face-to-face counseling sessions *The screening must be done in a primary care setting that can provide follow-up treatment and referrals. Who is Covered? Medicare beneficiaries, including pregnant women: Who misuse alcohol Whose levels of alcohol consumption do not meet criteria for alcohol dependence Who are competent and alert at the time of counseling If counseling is furnished by qualified primary care providers in a primary care setting What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

10. Bone Mass Measurement Measures bone density to detect Osteoporosis Covered once every 24 months or more often if medically necessary Who is Covered? Certain people at risk for losing bone mass: Woman who is estrogen–deficient and at risk due to medical history Individuals with vertebral abnormalities Individuals receiving (or expecting to receive) steroid therapy for more than 3 months Individual with hyperparathyroidism X-Rays show possible problems Individuals being monitored to assess their response to FDA approved osteoporosis drug therapy What Does the Beneficiary Pay? Nothing if doctor accepts assignment.

11. Cardiovascular Disease Risk Reduction Visit One CVD face to face risk reduction visit per year includes  Encouraging aspirin use for the primary prevention of CVD when the benefits outweigh the risks  Screening for high blood pressure in adults 18 or older  Intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular- and diet-related chronic disease Who is Covered? All people with Medicare. What Does the Beneficiary Pay? Nothing if doctor accepts assignment. Provided by a primary care provider in a primary care setting

12. Cardiovascular Disease Screening Cardiovascular blood screening test – Once every five years Total cholesterol test Cholesterol test for high density lipoproteins Triglycerides test Who is Covered? All Medicare beneficiaries who have not been previously diagnosed with cardiovascular disease. What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment.

13. Colorectal Cancer Screening Fecal Occult Blood Test – 12 months Flexible Sigmoidoscopy – 48 months Colonoscopy – 24 months Barium Enema – Substitute for colonoscopy or sigmoidoscopy Multi-target stool DNA test (Cologuard™) Who is Covered? All people with Medicare age 50 and older. No age limit for a colonoscopy. What Does the Beneficiary Pay? Nothing for the fecal occult blood test. Nothing for flexible sigmoidoscopy or screening colonoscopy, if doctor accepts assignment. For barium enemas, 20% of the Medicare-approved amount for the doctor’s services with no Part B deductible. If it’s done in a hospital outpatient setting, you pay a copayment

14. Screening Test If Normal Risk Covered Once Every If High Risk, Covered Once Every You Pay Screening Fecal Occult Blood Test 50 or older 12 months No deductible or copayment for this test Screening Flexible Sigmoidoscopy 50 or older 4 years or 10 years after a previous screening colonoscopy 4 yearsNo deductible or copayment for this test Screening Colonoscopy No minimum age 10 years (generally) or 4 years after a previous flexible sigmoidoscopy 24 months (unless a screening flexible sigmoidoscopy is performed, then only every 4 years) No deductible or copayment for this test

15. Screening Test If Normal Risk Covered Once Every If High Risk, Covered Once Every You Pay Screening Barium Enema 50 or older 4 years when used instead of a sigmoidoscopy or colonoscopy 24 months (as an alternative to a covered screening colonoscopy) There is no deductible for this test. You pay 20% of the Medicare- approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. Multi-target Stool DNA test (Cologuard ™ ) 3 years There is no deductible or copayment for this test.

16. Depression Screening Annual limited screening Various screening tools are available. Choice of tool at discretion of clinician Who is Covered? All people with Medicare What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment *The screening must be done in a primary care setting that can provide follow-up treatment and referrals.

17. Diabetes Screening Diabetes screening test – Twice yearly (Calendar year) with certain risk factors or if pre-diabetic. If not at risk covered once yearly. Fasting plasma glucose test Post-glucose challenge test Who is Covered? Any individuals with one of the following individual risk factors for diabetes is eligible for this new benefit: Hypertension, Dyslipidemia, Obesity BMI equal to or over 30 Previous identification of elevated impaired fasting glucose or glucose intolerance. Or, an individual with two of the following risk factors for diabetes is also eligible for this new benefit: Overweight (a body mass index greater than or equal to 25 km/m2) A family history of diabetes Age 65 years or older A history of gestational diabetes mellitus or giving birth to a baby weighing > 9 lbs. What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

18. Diabetes Self Management Training Training for people with Diabetes to help them manage their condition and prevent complications. Instruction in self monitoring blood glucose Education about diet and exercise. Insulin Treatment plan. Who is Covered? All people with Medicare who have diabetes. Up to 10 hours a year. What Does the Beneficiary Pay? 20% of the Medicare-approved amount after Part B deductible You must have a written order from your provider.

19. Glaucoma Screening Glaucoma is an eye disease caused by high pressure in the eye. It can develop gradually without warning and often without symptoms. Annual screening are a person’s best protection. Who is Covered? All persons determined to be high risk for glaucoma: Individuals with a family history Individuals with diabetes African-Americans, age 50 and older Hispanics, age 65 and older What Does the Beneficiary Pay? 20% of the Medicare-approved amount after Part B deductible Co-payment in a hospital outpatient setting

20. Hepatitis C Screening Test Hepatitis C virus (HCV) is a serious disease (virus attacks the liver) Can cause chronic liver disease Cirrhosis (scarring of the liver) Liver cancer, liver failure, and even death Who is Covered? Covered when ordered by primary care practitioner in a primary care setting Single, once-in-a-lifetime HCV screening test if born from 1945 to 1965 Annually, if high-risk person with prior negative HCV screening test What Does the Beneficiary Pay? No copayment or deductible with Original Medicare

21. Immunizations Flu – Once a year Pneumonia – Varies with health status Hepatitis B – If at medium to high risk for hepatitis Who is Covered? All people with Medicare Initial pneumococcal for all those that have not had the vaccine under Part B and will cover a different second vaccine 1 year after the first vaccine. What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

22. Lung Cancer Screening Medicare covers lung cancer screening with Low Dose Computed Tomography once per year for people with Medicare who meet all of Screening criteria Who is Covered? Are age 55-77 Are either a current smoker or have quit smoking within the last 15 years Have a tobacco smoking history of at least 30 “pack years” Get a written order from their doctor or qualified non-doctor practitioner What Does the Beneficiary Pay? You pay nothing for this service if the primary care doctor or other qualified primary care practitioner accepts assignment.

23. Breast Cancer Screening Once every 12 months Example: Mammogram performed on March 15; Medicare will pay for next Mammogram anytime after March 1 of following year W ho is Covered? All women with Medicare age 40 and older. One baseline mammogram is covered between ages 35-39 What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

24. Medical Nutrition Therapy Services can be given by a registered dietitian or Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Medicare covers 3 hours of one-on-one counseling services the first year, and 2 hours each year after that. Who is Covered? Certain people who have any of the following: Diabetes Renal disease (people who have kidney disease, but aren’t on dialysis) Had a kidney transplant within the last 3 years A referral from doctor is required What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

25. Obesity Screening and Counseling Intensive behavioral therapy includes: Screening for obesity using BMI measurement Dietary (nutritional) assessment Intensive behavioral counseling and behavioral therapy One face-to-face visit every week for the 1 st month One face-to-face visit every other week for months 2-6 One face-to-face visit every month for months 7-12, if the beneficiary meets the 6.6 lbs weight loss requirement (within the last 6 months Who is Covered? People with Medicare who have a body mass index of 30kg/m 2 or more What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

26. One-Time “Welcome to Medicare” Physical Examination This physical examination is a once-a-lifetime benefit for a new beneficiary. Covers a physical exam ( blood pressure, height, and weight); simple vision check ; review of medical and social history, mental health screening, functional ability and safety screening, end of life planning and education on staying well body mass index measurement. Who is Covered? New Medicare beneficiaries and the exam must be done within 1 year of Part B coverage effective date What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

27. Cervical and Vaginal Cancer Screening Pap test and pelvic exam with clinical breast exam Who is Covered? Covered for all women - Once every 24 months - Once every 12 months, if you’re either : - At high risk for cervical or vaginal cancer - Of childbearing age and had an abnormal Pap test in past 36 months What Does the Beneficiary Pay? Nothing for pap test specimen collection or the pelvic and breast exams if doctor accepts assignment

28. Prostate Cancer Screening Digital rectal exam – 12 months Prostate Specific Antigen (PSA) Test – 12 months Who is Covered? All men with Medicare age 50 and older What Does the Beneficiary Pay? 20% of the approved amount for the digital rectal exam after the Part B deductible Nothing for the PSA Test

29. Preventive Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) A one-time preventive ultrasound screening for abdominal aortic aneurysms (AAA). Ultrasound to detect weak area bulges in the aorta the largest artery in the body. Who is Covered? Beneficiaries who are at risk for AAA: Family history of AAA and/or Man - age 65-75 who has smoked at least 100 cigarettes (5 packs) in his lifetime What Does the Beneficiary Pay? Nothing if doctor accepts assignment

30. Sexually Transmitted Infections Screening and Counseling Sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. Covers up to two individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. Who is Covered? These screenings are covered for people with Medicare who are pregnant and/or for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. Medicare covers these tests once every 12 months or at certain times during pregnancy. Medicare will only cover these counseling sessions if they’re provided by a primary care provider and take place in a primary care setting, like a doctor’s office What Does the Beneficiary Pay? You pay nothing for STI screenings or counseling if the primary care doctor or primary care practitioner accepts assignment. Behavioral counseling sessions conducted in an inpatient setting, like a skilled nursing facility, won't be covered as a preventive service. (Counseling conducted in an inpatient setting, like a skilled nursing facility, won’t be covered as a preventive benefit.)

31. Tobacco Use Cessation Counseling Counseling from a “qualified doctor or other Medicare-recognized practitioner” who can help them stop using tobacco. The types of counseling are as follows: Intermediate cessation counseling (3 – 10 minute session) Intensive counseling (greater than 10 minutes per session) Coverage of 2 quit attempts per year. May include a maximum of 4 intermediate or intensive counseling sessions with the total annual benefit covering up to 8 sessions in a 12 month period Who is Covered? Any person who uses tobacco Must have a condition that is adversely affected by tobacco use or The metabolism or dosing of a medication that is being used to treat a condition a person has is being adversely affected by the tobacco use Medicare covers these counseling sessions as a preventive service if you haven’t been diagnosed with an illness caused by tobacco use What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

32. Yearly “Wellness” Exam A yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This includes the following: Review of medical and family history A list of current providers and prescriptions Height, weight, blood pressure, and other routine measurements Create a screening schedule for appropriate preventive services A list of risk factors and treatment options for you Screen for cognitive issues Who is Covered? Anyone who has had Part B for longer than 12 months. If you have had your “Welcome to Medicare” physical exam, you will have to wait 12 months before you can get your first yearly “Wellness” visit What Does the Beneficiary Pay? Nothing if doctor or provider accepts assignment

33. myMedicare.gov View claim status(excluding Part D claims) Order a duplicate Medicare Summary Notice or replacement Medicare card View eligibility, entitlement and preventive service info View or modify your drug list & pharmacy info View address of record with Medicare & Part B deductible status Access online forms, publications & messages sent to you by CMS

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35. Thank You!

36. You may reach CLAIM at: 1-800-390-3330 www.missouriclaim.org 1-800-726-7390 www.difp.mo.gov