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Increase Utilization of Preventive Services in Medicare and Medicaid
  1. Give the Centers for Medicare & Medicaid Services (CMS) authority to determine coverage for preventive services in Medicare.
  2. Extend the eligibility period and remove the deductible from the Welcome to Medicare Visit.
  3. Create an incentive for states to cover tobacco use screening and treatment in their Medicaid programs.

Intended Outcome: The purpose of this policy is to improve the health of Medicare and Medicaid beneficiaries by increasing their use of clinical preventive services that have been proven effective.

  1. Give CMS authority to determine coverage for preventive services in Medicare:
    The statute governing Medicare has consistently been interpreted as limiting coverage to diagnosis and treatment services. Thus, an act of Congress is required to expand or reduce Medicare coverage for clinical preventive services, and no mechanism currently exists for revisiting covered preventive services when new evidence emerges about appropriate screening technologies, periodicities, target populations, etc. Because the legislative process moves slowly, coverage has frequently not been aligned with the latest evidence. Also, because special interests often influence legislation about preventive service benefits, coverage is not always aligned with evidence-based recommendations.

    As result of the Medicare Modernization Act of 2003 and other recent changes, most preventive services currently recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices are currently covered under Medicare (albeit often with different co-pay and deductible requirements) after years of discrepancy between what is recommended and what is covered. However, problems remain and will continue to arise as more preventive services are proven to be effective. For example, the Advisory Committee on Immunization Practices recently approved the herpes zoster vaccine to prevent the painful disease shingles in older adults. However, because CMS does not have authority to cover preventive services under Part B, it cannot reimburse physicians for the cost of administering this vaccine to their patients. In other instances, Medicare coverage for preventive services is too generous, promoting inappropriate demand and overuse of services, which increases costs to Medicare with no corresponding health benefit. For example, Congress mandated that Medicare cover colonoscopy every 24 months for the detection of colorectal cancer. The American Cancer Society and the U.S. Preventive Services Task Force are in agreement that colonoscopy is only necessary every 10 years. Medicare also covers annual prostate cancer screening for all male beneficiaries, which is not recommended by the U.S. Preventive Services Task Force. The American Cancer Society recommends limiting screening to men over 50 with at least a 10-year life expectancy.

  2. Extend the eligibility period and remove the deductible from the Welcome to Medicare Visit:
    The Welcome to Medicare Visit (WMV), which was established by the Medicare Modernization Act of 2003, aims to encourage new Medicare enrollees to visit their primary care provider to obtain a preventive care plan. The value of the WMV is that it establishes a source of primary care for beneficiaries who lack access, and it provides a dedicated opportunity to emphasize the importance of prevention as patients enter the Medicare program. Beneficiaries can be reminded about the benefits of exercise, healthy diet, smoking cessation, and injury prevention, even after years of inattention. Clinicians can underscore the importance of recommended screening tests and immunizations and can either provide these services during the WMV or arrange referrals or future appointments.

    When it enacted the WMV, Congress chose not to waive the deductible for the visit. For new beneficiaries who have not met their deductible, the out-of-pocket costs ($124 for 2006) will likely dampen their interest in the WMV, especially among low-income individuals.

    In addition, the WMV must be used within the first 6 months of enrollment in Medicare. One barrier this presents is that beneficiaries may have difficulty making an appointment with a clinician within six months of enrolling in Medicare.Also, because the visit is limited to a small group of beneficiaries, it applies to only a few patients in any given physician practice. This makes it impractical for most primary care practices to organize themselves to promote and deliver the visit.

  3. Create incentives for states to cover tobacco use screening and treatment in their Medicaid programs:
    The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program mandates coverage for an array of preventive and diagnostic services for all children and adolescents enrolled in Medicaid. In contrast, however, coverage for preventive services for adults enrolled in Medicaid varies by state.

    The most important coverage gap for adults enrolled in Medicaid is coverage for tobacco use screening and treatment. 1 The National Commission on Prevention Priorities, chaired by former U.S. Surgeon General Dr. David Satcher, ranked 25 recommended preventive services, such as mammography, colorectal cancer screening, and flu shots, and found that the three preventive services offering the greatest health benefit and cost savings are 1) tobacco use screening and treatment; 2) childhood immunizations; and 3) advising high-risk adults about daily aspirin use. Increasing delivery of tobacco use screening and treatment above current levels would yield 1.3 million years of healthy life. The National Commission also found that providing tobacco use screening and treatment services to all tobacco users would save $500 in medical care costs per person treated (taking into account that many of those treated will not quit). This translates into billions of dollars of health care savings for the nation. 2

    As of December 31, 2005, 38 state Medicaid programs reported covering at least one form of tobacco-dependence treatment for all Medicaid beneficiaries. Only 14 states, however, offered some form of tobacco-cessation counseling for all Medicaid beneficiaries; 12 additional states covered counseling only for pregnant women. Only one state, Oregon, covers all treatments recommend by the U.S. Public Health Service guidelines. 3

    In March 2005, at the urging of Partnership for Prevention, CMS issued a rare national coverage decision requiring all Medicare carriers in the U.S. to pay for tobacco use screening and treatment for all beneficiaries with tobacco-related conditions or who are taking medications that could be affected by tobacco use.4 Thus, the government pays for tobacco use treatment for adults age 65 and older, but does so inconsistently for younger adults on Medicaid, who have more years to benefit from treatment.
Evidence/Effectiveness: Lack of reimbursement is a major barrier to improving utilization of preventive services. Rigorous studies have demonstrated, for example, that removing financial barriers increases vaccination rates and breast cancer screening. 5, 6 Reducing out-of-pocket costs has also been shown to increase use of tobacco cessation therapies. 7
Legislative Context:
Medicare: A string of bills, enacted by Congress between 1980 and 2003, expanded Medicare coverage to include many screening and immunization services, including the WMV that was passed in December 2003 and took effect on January 1, 2005.8 Thus, most preventive services for older Americans recommended by the USPSTF and ACIP are currently covered under Medicare, with the notable exceptions of hearing and vision screening. Some recommended counseling services are also not specifically covered (such as counseling patients to consider daily aspirin use and counseling women at high-risk about chemoprevention of breast cancer), although minimal counseling should be reimbursable as part of an evaluation and management (E&M) visit. The Deficit Reduction Act of 2005, signed by President Bush in February 2006, removed the deductible for colorectal cancer screening effective in 2007, but the 25% co-pay remains.

Medicaid: States have used the broad flexibility inherent in Medicaid to create many eligibility, coverage, and financing policies that meet the diverse needs of their populations and the states' own financial circumstances. Thus, population groups covered by Medicaid vary considerably by state. Senator Harkin is considering introducing a bill that would amend title XIX of the Social Security Act to encourage states to provide pregnant women enrolled in the Medicaid program with access to comprehensive tobacco cessation services. This bill would offer states the incentive of an enhanced federal medical assistance percentage (FMAP) match for covering a comprehensive tobacco cessation program for pregnant women enrolled in Medicaid. While pregnant women are certainly a key eligibility group in every state’s Medicaid program, Partnership believes it is important to encourage state Medicaid programs to cover comprehensive tobacco cessation for all adults enrolled in Medicaid (including pregnant women).


  1. The guidelines for this service that clinicians are admonished to follow come from the U.S. Public Health Service and have been consistent since 1996: all adults should be screened for tobacco use. Patients who use tobacco should be urged with a clear, strong, and individualized message that quitting is important to their health. Clinicians must also arrange for more intensive counseling, medications, and referrals to community programs.
  2. Maciosek MV, Coffield AB, Edwards NM, Goodman MJ, Flottemesch TJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006; 31(1):52-61 and Solberg LI, Maciosek MV, Edwards NM, Khanchandani HS, Goodman MJ. Repeated tobacco use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med 2006; 31(1):62-71.
  3. CDC. State Medicaid Coverage for Tobacco-Dependence Treatments --- United States, 2005. MMWR 11/10/06; 55(44): 1194-1197. http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5544a2.htm (last accessed December 11, 2006).
  4. Medicare will cover up to 8 brief or intensive counseling sessions in a 12-month period under Part B in addition to medication under Part D. The benefit is limited to those with tobacco-related conditions because CMS does not have the authority to cover preventive services. Tobacco users who do not yet have a tobacco-related condition (e.g., heart disease, cancer, hypertension, cholesterol, history of stroke, etc.) are not eligible for the benefit.
  5. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccine coverage in children, adolescents and adults. Am J Prev Med 2000; 18(IS):92-6.
  6. Task Force on Community Preventive Services. Promoting breast and cervical cancer screening in communities: Task Force findings on reduced client costs. http://thecommunityguide.org/cancer/screening/default.htm (last accessed October 30, 2006).
  7. Task Force on Community Preventive Services. Strategies for Reducing Exposure to Environmental Tobacco Smoke, Increasing Tobacco-Use Cessation, and Reducing Initiation in Communities and Health-Care Systems. MMWR November 10, 2000 / 49(RR12): 1-11.
  8. Coffield AB, Omenn GS, Fielding JE, Long PV, Kamerow DB. The camel's nose is under the tent: opportunities for prevention associated with the 2003 Medicare Act. Am J Prev Med 2004;6: 375-6.