MEDICARE’S PROPOSED REGULATION TO IMPLEMENT NEW PREVENTIVE SERVICES UNDER MEDICARE MODERNIZATION ACT
Today’s Action: The Centers for Medicare & Medicaid Services (CMS) proposed regulations to implement the preventive benefits provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). These provisions reflect modern medical practice by expanding the number of preventive services available to Medicare beneficiaries. Adding these services will continue Medicare’s evolution into a truly preventive care program.
Beginning in 2005, all newly enrolled Medicare beneficiaries will be covered for an initial physical examination, all beneficiaries will be covered for cardiovascular screening blood tests, and those at risk will be covered for a diabetes screening test in order to increase early detection and treatment of this life-threatening condition.
- Welcome to Medicare Physical. The initial preventive physical will consist of a comprehensive examination that will allow the physician to diagnose problems early when treatment is more effective. In addition the physician and office staff will provide education, counseling and referral to other preventive services covered by Medicare.
- Cardiovascular Screening Tests. Cardiovascular disease is the number one killer in the United States. Every year, some 950,000 persons die from this condition with 84 percent of those deaths occurring in people aged 65 and older. In 2001, more than 6 million Americans were admitted to the hospital with a diagnosis of cardiovascular disease, of which 64.5 percent were 65 or older. MMA will provide Medicare coverage of cardiovascular screening blood tests, including tests for total cholesterol, high density lipoprotein, and triglycerides. Beneficiaries will be allowed to be screened every five years in keeping with recommendations from the Unites States Preventive Services Task Force. There will be no deductible or co-pay for these tests.
- Diabetes Screening Tests. Diabetes ranks as the sixth leading cause of death, and was responsible for more than 71,000 deaths in 2001. In addition, 562,000 Americans were admitted to the hospital with a diagnosis of diabetes, or whom 36.6 percent were 65 and older. These tests to be covered under the proposed rule include a fasting plasma glucose test and post-glucose challenges. Beneficiaries eligible for this screen will not have to meet a deductible or co-pay for the test. MMA allows for diabetes screening tests up to twice year.
These benefits are in accordance with guidelines from the United States Preventive Services Task Force. These benefits are in line with and complement several administrative initiatives such as Healthy People 2010, Steps to a Healthier US, Secretary’s Diabetes Detection Initiative, and Healthy Communities.
Background: Each year, hundreds of thousands of Americans die prematurely as a result of diseases that often are preventable, such as heart disease, cancer, and diabetes. Evidence suggests that catching a disease in its early stages brings better prognosis for the patient. The course of many of these chronic diseases can be dramatically slowed with proper behavioral modifications and lifestyle changes. This points to the need for the early detection that screening provides.
The number of Americans with these diseases is staggering. Heart disease and stroke—the principal components of cardiovascular disease—are the first and third leading causes of death for both men and women in the United States, accounting for nearly 40% of all deaths. In addition, according to CDC, one in five adults age 65 and over has diabetes. A third of people with diabetes don’t know they have it. The costs of these diseases to both individuals and to society are staggering. The economic impact of cardiovascular disease on the U.S. health care system continues to grow as the population ages. The cost of heart disease and stroke in the United States is projected to be $368 billion in 2004, including health care expenditures and lost productivity from death and disability. Approximately 129 million U.S. adults are overweight or obese which costs between $69 billion to $117 billion per year. Smaller amounts might be spent preventing these conditions. There is accumulating evidence that much of the morbidity and mortality associated with these chronic diseases may be preventable. These new benefits can be used to screen Medicare beneficiaries for many illnesses and conditions that, if caught early, can be treated and managed, and can result in far fewer serious health consequences.
OTHER CMS PREVENTIVE BENEFITS
When Medicare was established in 1965, it only provided services for the diagnosis and treatment of illness or injury. Preventive services were not covered. As the value of preventive services has become better understood, Congress has amended the Medicare law in an effort to expand coverage of preventive benefits.
Both the Balanced Budget Act of 1997 (BBA) and the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) significantly added to the preventive benefits covered by Medicare. These benefits include:
- Mammography screening: BBA provided coverage for an annual screening mammogram for all women Medicare beneficiaries age 40 and over, and one baseline mammogram for women age 35-39. There is no Part B deductible for screening mammography. BIPA moved payment for screening mammography to the physician fee schedule and also specified payment for two new forms of mammography that use digital technology
- Screening Pap Smears and Pelvic Exams: BBA provided coverage for a screening Pap smear and pelvic exam (including a clinical breast exam) every 3 years, or annual coverage for women of childbearing age who have had an abnormal Pap smear during the preceding 3 years, or women at high risk for cervical or vaginal cancer. There is no Part B deductible for screening pap smears and pelvic exams. BIPA increased the frequency of coverage for screening Pap smears and pelvic exams (including a clinical breast exam) from every 3 years to every 2 years for women at average risk.
- Colorectal Cancer Screening: BBA provided new coverage for colorectal cancer screening procedures including (1) annual fecal-occult blood tests for persons age 50 and over, (2) flexible sigmoidoscopy for persons age 50 and over, every 4 years, (3) colonoscopy for persons at high risk for colorectal cancer, every 2 years, and (4) other procedures the Secretary finds appropriate. Barium enemas are also covered, as an alternative to flexible sigmoidoscopy or colonoscopy. BIPA expanded coverage of screening colonoscopies to include all beneficiaries, not just those at high risk for colorectal cancer.
- Prostate Cancer Screening: BBA provided coverage of annual prostate cancer screening for men over age 50, including (1) digital rectal exams, (2) prostate-specific antigen (PSA) blood tests, and (3) after 2002, other procedures the Secretary finds appropriate.
- Glaucoma screening: BIPA provided coverage of annual glaucoma screening for individuals at high risk for glaucoma, individuals with a family history of glaucoma, and individuals with diabetes.
- Medical nutrition therapy services: BIPA provided coverage of medical nutrition therapy services for beneficiaries who have diabetes or a renal disease. Covered services include nutritional diagnostic, therapy and counseling services for the purpose of disease management, which are furnished by a registered dietician or nutrition professional, pursuant to a physician’s referral.
- Self-management training for beneficiaries with diabetes: These services are provided by certified diabetes educators.
- Standardization of Coverage for Bone Mass Measurements: BBA provided coverage for bone mass measurement procedures, including a physicians interpretation of the results, for estrogen-deficient women at risk for osteoporosis, and persons (1) with vertebral abnormalities, (2) receiving long-term glucocorticoid steroid therapy, (3) with primary hyperparathyroidism, and (4) being monitored for response to an osteoporosis drug.
- Vaccines Outreach Extension: BBA extended through FY 2002 the existing Influenza and Pneumococcal Vaccination Campaign conducted by HCFA in conjunction with CDC and the National Coalition for Adult Immunization. Medicare covers influenza, pneumococcal, and hepatitis B vaccinations, including payment for the vaccine plus payment for a physician’s administration of the vaccine.
- Study on Preventive and Enhanced Benefits: BBA required an analysis of short and long term costs and benefits of expanding or modifying preventive or other services covered by Medicare, to be conducted by the National Academy of Sciences in conjunction with the U.S. Preventive Services Task Force. The study was completed in December 1999.
CMS’ PREVENTIVE BENEFITS OUTREACH
We can demonstrate the benefits of preventive health care services, but we also know that simply offering these services is not always enough to guarantee that Medicare beneficiaries take advantage of the benefits that they provide. CMS is taking significant steps to reach out and educate beneficiaries about these new benefits and encourage participation. We strive to use efficient and cost-effective approaches by partnering with other agencies and organizations, utilizing Medicare contractors to educate people with Medicare about covered preventive services and encouraging beneficiaries to use these services. Several initiatives are planned to inform new enrollees about the initial physical exam benefit.
Medicare & You 2005 Handbook
Beginning October 2004, this publication will include information about this new benefit. Copies are mailed directly to new enrollees each month. Beginning in January 2005, CMS will add prominent, targeted information about the physical exam to the versions that are mailed to new enrollees.
“Guide to Medicare’s Preventive Services” publication
In Fall 2004, this publication will explain the new benefit. Beneficiaries, caregivers, health care professionals, and information intermediaries can request a free copy from www.medicare.govand 1-800-MEDICARE.
2-page Preventive Services Fact Sheet
In late Fall 2004, a 2-page fact sheet will provide an overview of this benefit. It will be available from www.medicare.gov and 1-800-MEDICARE.
Initial Enrollment Period (IEP) Package
Work has started on an update and redesign of the Initial Enrollment Period Package, which may include information about this new benefit. CMS expects to begin mailing the new package after September 2005 to newly eligible beneficiaries.
Ongoing meetings and presentations with advocacy and outreach groups
CMS staff will take advantage of existing opportunities to share information about the physical exam with these groups.
1-800-MEDICARE
Call center operations staff will add relevant scripts to all call center desktops. Call center operations staff will add tips to relevant call center scripts that will cue customer service representatives to inform new enrollees of benefit.
Educating the providers
CMS will provide primary care physicians and other health care professionals with materials via various channels, including MedLearn website, to help them communicate this benefit to beneficiaries.
We include health promotion information as a part of many education campaigns that address different aspects of the Medicare program or Medicare Advantage options. We have established partnerships with other HHS agencies to carry out health promotion initiatives ranging from limited distributions of outreach kits to national multi-media, multi-year campaigns involving numerous partners at the local and national level. Preventive service use is growing and CMS hopes that these changes to Medicare encourage our beneficiaries to take advantage of these health-promoting activities and ultimately increase the length and quality of life for our senior Americans.