Frequently Asked Questions (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. For more information on USPSTF recommendations, visit http://www.uspreventiveservicestaskforce.org/recommendations.htm on the Internet. Watch for announcements of additional new preventive benefits and educational materials at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html on the cms website, or refer to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNProducts_listserv.pdf to sign up to receive news of new Medicare learning network® (mln) products by e-mail. For the latest information on medicare preventive services, visit http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/News_and_Announcements.html on the CMS website.

Some services must be performed in a primary care setting. What is that?

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. We do not consider Ambulatory Surgical Centers (ASCs), emergency departments, hospices, independent diagnostic testing facilities, inpatient hospital settings, Inpatient Rehabilitation Facilities (IRFs), and Skilled Nursing Facilities (SNFs) 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.

My patients do not follow up on routine preventive care. How can I help them remember when they are due for their next preventive service?

Medicare.gov provides a “Preventive Screening Checklist” that you can give to your patients. They can use the checklist to track their preventive services. for the checklist, visit http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-checklist.aspx on the Internet.