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CMS Prevention and Wellness Services Beneficial in Long Term Care Setting [Ober|Kaler]

Health Law Alert

Medicare beneficiaries mainly use the fee-for-service benefits the program makes available, and health care providers are used to thinking of the program as covering health care services and items in response to medical needs. Consumers familiar with managed care systems, whether for the first time under Medicare Advantage or transitioning from commercial products such as health maintenance organizations, may be more used to using benefits and services designed to avoid illness or injury.

Long term care providers, particularly those working in a continuing care retirement community, assisted living, senior housing, adult day care or a new "village" model focused on community-based services, would do well to consider the increasingly robust array of prevention and wellness services the Centers for Medicare and Medicaid Services (CMS) makes available to traditional, fee-for-service beneficiaries. These services not only have the potential for obvious benefits to seniors, but they also provide an additional framework for an ongoing, medically proactive relationship with seniors that has practice development benefits. Offering prevention and wellness services can have marketing advantages too, as the provider in a community or senior care setting is able to hold itself out as a center for prevention and wellness, rather than healing and maintenance of function alone.

As a result of the federal health reform law, the Affordable Care Act, Medicare coverage for many of these services, without cost to patients, became available in 2011.

Preventive Services and Screenings covered by Medicare include:

  • Initial Preventive Physical Examination (IPPE), also known as the "Welcome to Medicare" visit (includes a referral for an ultrasound screening for Abdominal Aortic Aneurysm for eligible beneficiaries)
  • Annual Wellness Visit (including Personalized Prevention Plan Services)
  • Bone Mass Measurement
  • Cancer Screenings
    • Breast Cancer (mammography and clinical breast exam)
    • Cervical and Vaginal Cancer (pap test and pelvic exam (includes the clinical breast exam))
    • Colorectal Cancer
    • Fecal Occult Blood Test
    • Flexible Sigmoidoscopy
    • Colonoscopy
    • Barium Enema
    • Prostate (PSA blood test and Digital Rectal Exam)
  • Cardiovascular Disease Screening
  • Diabetes Screening and Self-management Training
  • Glaucoma Screening
  • Sexually Transmitted Disease Screenings
    • Human Immunodeficiency Virus (HIV)
    • Sexually Transmitted Infections (STIs)
    • High-intensity Behavioral Counseling (HIBC) to prevent STIs
  • Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
  • Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
  • Tobacco-use Cessation Counseling
  • Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse
  • Screening for Depression in Adults
  • Intensive Behavioral Therapy for Cardiovascular Disease
  • Intensive Behavioral Therapy for Obesity

To aid beneficiaries and providers, CMS publishes a chart that describes (a) each prevention and wellness service; (b) the applicable HCPCS and CPT Codes to be documented; (c) the relevant ICD-9 Codes; (d) who is covered under this Medicare benefit; (e) the frequency of the available benefit; and (f) the amount, if any, the beneficiary pays. CMS also has made available a booklet entitled, "Preventive Services, Medicare Immunization Billing, The ABCs of Providing the Initial Preventive Physical Examination and The ABCs of Providing the Annual Wellness Visit" under the MLN Network. Individual brochures, guides, quick reference information charts and fact sheets are also available.

CMS provides more essential, detailed guidance in its Claims Processing Manual at chapter 18, and in its Benefit Policy Manual at chapter 15. These manual provisions provide important information that is separately set out for each benefit such as when the beneficiary qualifies for the covered service, whether physician supervision is required, the credentials of physician and nonphysician practitioners authorized to provide the service, whether the facility in which the service is rendered needs any sort of special approval, how one provider may obtain and bill for the service "under arrangement" with another provider, or whether there are circumstances under which the Medicare deductible may not apply but to which coinsurance might be applicable.

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