pneumonia vaccine. Table 6–1 lists the preventive services that Congress has now authorized for coverage. For several of these services, Congress has waived application of the Part B deductible and 20 percent coinsurance. Frequency limits are also specified for several services, and coverage is sometimes conditional on the presence of certain risk factors.

All the covered services listed in the body of Table 6–1 involve either primary prevention (keeping people from developing disease) or secondary prevention (identifying risk factors or detecting disease early) as discussed in Chapter 3. The service noted in the footnote—outpatient self-management training and supplies for diabetics—falls in the category of tertiary preventive services, which is more typically described as patient management for those already diagnosed with a medical problem. The discussion below considers only primary and secondary preventive services.

Given Medicare’s statutory goal of covering “medically necessary” services and the committee’s experience with the work of the U.S. Preventive Services Task Force (USPSTF) in assessing evidence about the effectiveness of various

TABLE 6–1 Preventive Services Covered by Medicare

Service (effective date of coverage)

Special Provisions

Pneumococcol vaccine (1981)

No coinsurance; deductible not applied

Hepatitis B vaccine (1984)

High- or intermediate-risk beneficiaries

Cervical cancer screening by Pap smear (1990) and pelvic examination (1998)

Every 3 years for most beneficiaries; 20% coinsurance; deductible not applied

Influenza vaccine (1991)

No coinsurance, deductible not applied

Breast cancer screening by mammography (1991, 1998)

Every year for beneficiaries ≥40; 20% coinsurance, no deductible

Colorectal cancer screening (1998)

20% coinsurance, deductible applied; details differ for different tests and risk groups

Osteoporosis screening by bone densitometry (1998)

For high-risk beneficiaries; 20% coinsurance and deductible applied

Prostate cancer screening by prostate specific antigen (PSA) and digital rectal examination DRE (2000)

No cost sharing for PSA; 20% coinsurance; deductible for DRE

NOTE: In 1997, Congress also added coverage for outpatient self-management training and supplies for those diagnosed with diabetes.

SOURCE: HCFA, 1999b, Carriers Manual, Chapter 3 (which includes other details about coverage administration for these services).



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