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Preventive health services, preventive services for all adults, women, and children.

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Women’s Preventive Services Guidelines

Affordable care act expands prevention coverage for women's health and well-being.

The Affordable Care Act (ACA) – the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23, 2010 – helps make prevention services affordable and accessible for all Americans by requiring most health insurance plans to provide coverage without cost sharing for certain recommended preventive services. Preventive services that have strong scientific evidence of their health benefits must be covered and plans can no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider.

Under the ACA, most private health insurers must provide coverage of women's preventive health care – such as mammograms, screenings for cervical cancer, prenatal care, and other services –with no cost sharing. Under section 2713 of the Public Health Service Act, as modified by the ACA, non-grandfathered group health plans and non-grandfathered group and individual health insurance coverage are required to cover specified preventive services without a copayment, coinsurance, deductible, or other cost sharing, including preventive care and screenings for women as provided for in comprehensive guidelines supported by HRSA for this purpose.

The law recognizes and HHS understands the unique health needs of women across their lifespan. The purpose of WPSI is to improve women’s health across the lifespan by identifying preventive services and screenings to be used in clinical practice and, when supported by HRSA, incorporated in the Guidelines.

HRSA-Supported Women's Preventive Services Guidelines: Background

The HRSA-supported Women’s Preventive Services Guidelines (Guidelines) were originally established in 2011 based on recommendations from a Department of Health and Human Services' commissioned study by the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM).

Since the establishment of the Guidelines, there have been advancements in science and gaps identified in clinical practice. To address these, in 2016, the Health Resources and Services Administration (HRSA) awarded a five-year cooperative agreement, the Women’s Preventive Services Initiative (WPSI), to the American College of Obstetricians and Gynecologists (ACOG) to convene a coalition of clinician, academic, and consumer-focused health professional organizations to conduct a scientifically rigorous review to develop recommendations for updated Guidelines in accordance with the model created by the NAM Clinical Practice Guidelines We Can Trust. The American College of Obstetricians and Gynecologists (ACOG) formed an expert panel, also called the WPSI, for this purpose.

In March 2021, ACOG was awarded a subsequent cooperative agreement to review and recommend updates to the Guidelines. Under ACOG, WPSI reviews existing Women’s Preventive Services Guidelines biennially, or upon the availability of new evidence, as well as new preventive services topics. New topics for future consideration can be submitted on a rolling basis at the Women’s Preventive Services Initiative website .

HRSA-Supported Women's Preventive Services Guidelines

HRSA supports the Women’s Preventive Services Guidelines (Guidelines) listed below that address health needs specific to women. 

In December 2022, HRSA approved updates to the Guidelines for two listed preventive services:  Screening for Gestational Diabetes Mellitus (to be retitled as “Screening for Diabetes in Pregnancy”) and Screening for Diabetes Mellitus after Pregnancy (to be retitled as “Screening for Diabetes after Pregnancy”). The Guidelines are provided in the table below. 

Updated Guidelines

Current guidelines, implementation considerations.

While not included as part of the HRSA-supported guidelines, the Women's Preventive Services Initiative, through ACOG, also developed implementation considerations, available at the Women's Preventive Services Initiative website , which provide additional clarity on implementation of the guidelines into clinical practice. The implementation considerations are separate from the clinical recommendations, are informational, and are not part of the formal action by the Administrator under Section 2713.

* Non-grandfathered plans and coverage (generally, plans or policies created or sold after March 23, 2010, or older plans or policies that have been changed in certain ways since that date) are required to provide coverage without cost sharing consistent with these guidelines beginning with the first plan year (in the individual market policy year) that begins on or after December 30, 2022. Before that time, non-grandfathered plans are generally required to provide coverage without cost sharing consistent with the guidelines as previously updated in 2019.

** (I)(a) Objecting entities—religious beliefs.

(1) These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to a group health plan established or maintained by an objecting organization, or health insurance coverage offered or arranged by an objecting organization, and thus the Health Resources and Service Administration exempts from any Guidelines requirements issued under 45 CFR 147.130(a)(1)(iv) that relate to the provision of contraceptive services: (i) A group health plan and health insurance coverage provided in connection with a group health plan to the extent the non-governmental plan sponsor objects as specified in paragraph (I)(a)(2) of this note. Such non-governmental plan sponsors include, but are not limited to, the following entities: (A) A church, an integrated auxiliary of a church, a convention or association of churches, or a religious order; (B) A nonprofit organization; (C) A closely held for-profit entity; (D) A for-profit entity that is not closely held; or (E) Any other non-governmental employer; (ii) An institution of higher education as defined in 20 U.S.C. 1002 in its arrangement of student health insurance coverage, to the extent that institution objects as specified in paragraph (I)(a)(2) of this note. In the case of student health insurance coverage, section (I) of this note is applicable in a manner comparable to its applicability to group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor that is an employer, and references to “plan participants and beneficiaries” will be interpreted as references to student enrollees and their covered dependents; and (iii) A health insurance issuer offering group or individual insurance coverage to the extent the issuer objects as specified in paragraph (I)(a)(2) of this note. Where a health insurance issuer providing group health insurance coverage is exempt under this paragraph (I)(a)(1)(iii), the plan remains subject to any requirement to provide coverage for contraceptive services under these Guidelines unless it is also exempt from that requirement.

(2) The exemption of this paragraph (I)(a) will apply to the extent that an entity described in paragraph (I)(a)(1) of this note objects to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage, payments, or a plan that provides coverage or payments for some or all contraceptive services, based on its sincerely held religious beliefs. (b) Objecting individuals—religious beliefs. These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to individuals who object as specified in this paragraph (I)(b), and nothing in 45 CFR 147.130(a)(1)(iv), 26 CFR 54.9815–2713(a) (1)(iv), or 29 CFR 2590.715-2713(a)(1)(iv) may be construed to prevent a willing health insurance issuer offering group or individual health insurance coverage, and as applicable, a willing plan sponsor of a group health plan, from offering a separate benefit package option, or a separate policy, certificate or contract of insurance, to any individual who objects to coverage or payments for some or all contraceptive services based on sincerely held religious beliefs.

(II)(a) Objecting entities—moral convictions.

(1) These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to a group health plan established or maintained by an objecting organization, or health insurance coverage offered or arranged by an objecting organization, and thus the Health Resources and Service Administration exempts from any Guidelines requirements issued under 45 CFR 147.130(a)(1)(iv) that relate to the provision of contraceptive services: (i) A group health plan and health insurance coverage provided in connection with a group health plan to the extent one of the following non-governmental plan sponsors object as specified in paragraph (II)(a)(2) of this note: (A) A nonprofit organization; or (B) A for-profit entity that has no publicly traded ownership interests (for this purpose, a publicly traded ownership interest is any class of common equity securities required to be registered under section 12 of the Securities Exchange Act of 1934); (ii) An institution of higher education as defined in 20 U.S.C. 1002 in its arrangement of student health insurance coverage, to the extent that institution objects as specified in paragraph (II)(a)(2) of this note. In the case of student health insurance coverage, section (I) of this note is applicable in a manner comparable to its applicability to group health insurance coverage provided in connection with a group health plan established or maintained by a plan sponsor that is an employer, and references to “plan participants and beneficiaries” will be interpreted as references to student enrollees and their covered dependents; and (iii) A health insurance issuer offering group or individual insurance coverage to the extent the issuer objects as specified in paragraph (II)(a)(2) of this note. Where a health insurance issuer providing group health insurance coverage is exempt under this paragraph (II)(a)(1)(iii), the group health plan established or maintained by the plan sponsor with which the health insurance issuer contracts remains subject to any requirement to provide coverage for contraceptive services under these Guidelines unless it is also exempt from that requirement.

(2) The exemption of this paragraph (II)(a) will apply to the extent that an entity described in paragraph (II)(a)(1) of this note objects to its establishing, maintaining, providing, offering, or arranging (as applicable) coverage or payments for some or all contraceptive services, or for a plan, issuer, or third party administrator that provides or arranges such coverage or payments, based on its sincerely held moral convictions. (b) Objecting individuals—moral convictions. These Guidelines do not provide for or support the requirement of coverage or payments for contraceptive services with respect to individuals who object as specified in this paragraph (II)(b), and nothing in § 147.130(a)(1)(iv), 26 CFR 54.9815–2713(a) (1)(iv), or 29 CFR 2590.715-2713(a)(1)(iv) may be construed to prevent a willing health insurance issuer offering group or individual health insurance coverage, and as applicable, a willing plan sponsor of a group health plan, from offering a separate policy, certificate or contract of insurance or a separate group health plan or benefit package option, to any individual who objects to coverage or payments for some or all contraceptive services based on sincerely held moral convictions.

(III) Definition. For the purposes of this note, reference to “contraceptive” services, benefits, or coverage includes contraceptive or sterilization items, procedures, or services, or related patient education or counseling, to the extent specified for purposes of these Guidelines.

See Federal Register Notice: Religious Exemptions and Accommodations for Coverage of Certain Preventive Services under the Affordable Care Act (PDF - 474 KB)

*** General Notice On July 29, 2019, the District Court for the Northern District of Texas issued an injunction preventing the enforcement of “the Contraceptive Mandate, codified at 42 U.S.C. § 300gg–13(a)(4), 45 C.F.R. § 147.130(a)(1)(iv), 29 C.F.R. § 2590.715–2713(a)(1)(iv), and 26 C.F.R. § 54.9815–2713(a)(1)(iv), against any group health plan, and any health insurance coverage provided in connection with a group health plan, that is sponsored by an Employer Class member[,]” to the extent that such coverage conflicts with the Employer Class member’s sincerely held religious objections to such coverage, in connection with DeOtte v. Azar, No. 4:18-CV-00825-O, 2019 WL 3786545 (N.D. Tex. July 29, 2019). The injunction also prevents the enforcement of “the Contraceptive Mandate” to the extent it requires an "Individual Class member[] to provide coverage or payments for contraceptive services" to which the individual objects based on sincerely held religious beliefs, if a health insurance issuer and, if applicable, a sponsor of a group health plan, is willing to offer the Individual Class member a separate policy or plan that omits such contraceptive coverage. On December 17, 2021, the Fifth Circuit vacated the injunction in DeOtte v. Nevada, No. 19-10754 (5th Cir. Dec. 17, 2021). However, as of the date of this publication, the Fifth Circuit has yet to issue a mandate in connection with its order, and the injunction remains in place.

**** Education and counseling includes all methods of contraception, including but not limited to, hormonal, devices, surgical, barrier, and fertility-based awareness methods, including lactation amenorrhea.

***** FDA's Birth Control Guide This refers to  FDA’s Birth Control Guide  (PDF - 450 KB) as posted on December 22, 2021 with the exception of sterilization surgery for men, which is beyond the scope of the WPSI.

****** Notice This sentence, included at the end of the "Contraception" section of the previous Guidelines, remains at the conclusion of the "Contraception" section of the 2021 Guidelines per a Final Order issued on December 6, 2022, in Tice-Harouff v. Johnson, Eastern District of Texas (Tyler Division), Case No. 6:22-cv-201-JDK. This is consistent with footnote **** above, which indicates that education and counseling within the "Contraception" section of the 2021 Guidelines includes fertility awareness-based methods, including lactation amenorrhea.

[email protected] .

• HRSA/MCHB Preventive Guidelines and Screening for Women, Children, and Youth
• Historical Files
• 2019 Guidelines
• 2016 Guidelines
• Institute of Medicine:  Clinical Preventive Services for Women  (2011)
• Bright Futures
• Advisory Committee on Heritable Disorders in Newborns and Children

Providing Medicare wellness visits can be challenging but can improve quality and practice revenue.

ARNOLD E. CUENCA, DO, CAQSM, FAAFP, AND SUSAN KAPSNER, CCS

Fam Pract Manag. 2019;26(2):25-30

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: This is a corrected version of the article previously published.

The Affordable Care Act of 2010 created the Medicare annual wellness visit (AWV) as a way to provide patients with comprehensive preventive care services at no cost. Yet many practices have been slow to provide substantial numbers of these visits. Only 15.6 percent of eligible patients received an AWV through 2014. 1 In addition to finding lackluster overall participation, researchers have found AWV rates are lower among practices caring for underserved populations, such as racial minorities, rural residents, or those dually enrolled in Medicaid. 2

Physicians and other health care providers do not offer AWVs to their Medicare patients for numerous reasons. Providing and documenting all of the required AWV elements efficiently can be challenging, and some practices may feel their staffing or electronic health record resources are too limited. Many patients and even some physicians may not know what the AWV entails, and patients with complex socioeconomic risk factors may have pressing health conditions that need to take priority over preventive services. These explanations can all be valid, but this article seeks to help physicians reevaluate the AWV, along with the initial preventive physical examination (IPPE) or “Welcome to Medicare” visit, and recognize the value these wellness visits can bring not only to their patients but also to their practices or health care organizations.

The Medicare annual wellness visit (AWV) and the initial preventive physical examination (IPPE) provide a number of benefits to patients and physicians, but many physicians still do not provide them.

Medicare wellness visits can help physicians address care gaps and report quality measures important in pay-for-performance systems.

When billed correctly and delivered efficiently along with other covered Medicare preventive services, AWVs can boost practice revenue.

THE VALUE OF MEDICARE WELLNESS VISITS

The main benefit of the AWV to patients is the creation of a personalized prevention plan, a written plan that can help guide their preventive care decisions for the next five to 10 years. This plan includes age-appropriate preventive services, recommendations offered by both the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices, and personalized health advice that identifies risk factors and suggests referrals or programs to address them. 3

Providing Medicare wellness visits also offers a structure that helps physicians to close many pay-for-performance quality measure gaps, including those recognized by the Core Quality Measures Collaborative, the Integrated Healthcare Association’s California Value Based P4P program, and the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set. In addition, accountable care organizations participating in the Medicare Shared Savings Program can use data collected during wellness visits to satisfy specific quality measures for the 2018 and 2019 quality reporting years. 4 (See “ Closing quality measure gaps .”)

There also are financial incentives to implementing AWVs. Physicians participating in Medicare’s Merit-based Incentive Payment System (MIPS) can use AWVs to raise their quality scores, which can potentially lead to positive Medicare payment adjustments. Practices that provide AWVs often generate greater revenue than those that do not – a result of billing AWVs with associated preventive services and same-day problem-oriented services. 2 AWVs also provide physicians another opportunity to assess and report risk-adjusted diagnoses for Medicare Advantage beneficiaries. Future payment rates for higher risk patients are calculated based on risk-adjusted factor (RAF) scores, so addressing Hierarchical Condition Category-related diagnoses in the same visit can be of additional value. (For more on this subject, see “ Is Your Diagnosis Coding Ready for Risk Adjustment? ” FPM , March/April 2018, and “ Diagnosis Coding for Value-Based Payment: A Quick Reference Tool ,” FPM , March/April 2018.)

CLOSING QUALITY MEASURE GAPS

Many pay-for-performance measures can be addressed during Medicare wellness visits, including these, which are associated with the following programs: Core Quality Measures Collaborative (Collaborative), the Integrated Healthcare Association’s California Value Based P4P Program (IHA), and the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS). Measures used by the Medicare Shared Savings Program (MSSP) 2018 and 2019 reporting years are also listed.

HOW TO CODE FOR MEDICARE WELLNESS VISITS

The type of wellness visit you report depends on when the patient joined Medicare.

The IPPE is a one-time physical exam performed within the first 12 months of a patient’s enrollment under Part B Medicare. The initial AWV can be provided 12 months after the patient first enrolled or 12 months after he or she received the IPPE. A subsequent AWV can then be provided annually.

Physicians should bill for preventive services provided in addition to the AWV or IPPE, many of which carry work relative value units (wRVUs) that can affect their productivity scores and revenue. Some of these services are payable by Medicare in addition to the AWV or IPPE and can be performed several times during the year. However, patients and physicians should be aware that a few of these services do have a copay or deductible. (See “ Medicare-covered preventive services .”)

MEDICARE-COVERED PREVENTIVE SERVICES

This table includes preventive services that generate work relative value units (wRVUs). For a complete list of Medicare preventive services, see https://go.cms.gov/2sK65XA .

If you provide advance care planning (ACP), CPT code 99497 or 99498, at the same visit, make sure to append modifier 33, “Preventive service,” so that the usual coinsurance and deductible charged for the ACP is waived. 5 You may need to append modifiers to other preventive service codes as well, to avoid bundling. Practices should check with their Medicare contractor for guidance.

To find out how many wRVUs a particular service is worth, see the 2019 Medicare Physician Fee Schedule ) or the wRVU calculator provided by the American Academy of Professional Coders.

Below are some examples of wellness visits and the wRVUs resulting from each one.

Patient 1 : A 67-year-old male, who is an established patient of your practice, is seeing you for an initial AWV. His chronic problems include hypertension and dyslipidemia. He is taking hydrochlorothiazide 25 mg per day and atorvastatin 20 mg at bedtime. His history and the health risk assessment he completed confirm he has smoked one pack of cigarettes per day for 34 years. He does not have an advance directive. He rarely drinks alcohol, and his PHQ-2 depression screening score is zero. His vital signs are stable with good blood pressure control. His BMI is 33.7. He requests a digital rectal exam (DRE) because his father had prostate cancer. You create the patient’s personalized prevention plan and discuss your clinical recommendations with the patient, who agrees to receive several preventive services, including a lipid panel, diabetes screening, hepatitis C screening, lung cancer screening with a low-dose CT scan, a pneumococcal vaccination, a DRE, and AAA screening with ultrasound. You order the labs and imaging, provide counseling focused on several of the patient’s health risk behaviors, and recommend a follow-up visit in six months or sooner if needed to address test results.

Patient 2 : A 77-year-old female, who is an established patient of your practice, is seeing you for her first AWV. She has a Medicare Advantage insurance plan. Her previous office visit was about nine months ago. She has diabetes, hypertension, peripheral neuropathy, glaucoma, mild major depression, anxiety, and COPD. She is due for her routine lab work and is requesting refills of all her medications. She would like a flu shot, but the rest of her immunizations are current. Her list of medications includes metformin 500 mg twice a day, sitagliptin 50 mg daily, lisinopril 10 mg daily, gabapentin 300 mg three times per day, albuterol as needed, tiotropium daily, alprazolam 0.25 mg daily as needed, sertraline 50 mg daily, and dorzolamide ophthalmic twice a day. She has tried in the past to wean herself off the alprazolam but needs it to control her anxiety; she fills her prescription for 30 pills every three or four months, which you confirm via a controlled substance prescription database. Her history, along with her health risk assessment, shows she drinks up to three glasses of wine per day. She does not have an advance directive. Her vital signs are stable with good blood pressure control, and her BMI is 22.4. You address her concerns and order labs appropriate to her chronic medical conditions, refill her medications, order a flu shot, provide counseling related to her health risk behaviors, and discuss your preventive service recommendations as part of her personalized prevention plan, which includes ordering a DEXA scan.

Given the complexity of her health status, you ask her to schedule a follow-up appointment in one week to go over her lab results. Also, because the patient is a Medicare Advantage beneficiary, you remember to assess and report risk-adjusted diagnoses and HCC codes.

Patient 3 : A 57-year-old female, who is an established patient of your practice, recently became disabled. She now has dual insurance coverage with Medicare and Medicaid. She is scheduled for her “Welcome to Medicare” visit. She was seeing a partner of yours who recently retired, and she has transferred to you for care. Her last visit was four weeks ago, and her diabetes lab work at that time showed that her A1C was 6.7 and her LDL was 94. She had her annual eye exam two months ago. She has diabetes, hypertension, and end-stage renal disease (ESRD). Her list of medications includes insulin glargine 10 units at bedtime, insulin aspart on a sliding scale, amlodipine 5 mg daily, and pravastatin 10 mg at bedtime. Her history, along with her health risk assessment, shows that she has multiple sex partners. She does not drink alcohol and does not smoke. Her PHQ-2 depression screening is 0. Her last mammogram was three years ago, and her last Pap smear was six years ago. She has not received her pneumococcal vaccine. She has never had a colonoscopy or fecal occult blood testing. Her vital signs are stable with good blood pressure control and a BMI of 27.1. She has been feeling sick for the last two weeks with sinus infection symptoms. You treat her for a sinus infection, perform a gynecologic exam and Pap smear, and update her pneumococcal vaccination. You discuss and then order screens for hepatitis B, hepatitis C, HIV, and sexually transmitted infections (STIs), in addition to a mammogram. You also agree to make referrals for a colonoscopy and medical nutrition therapy for ESRD. Finally, you ask her to follow up in four to six months or as needed.

MEETING THE CHALLENGE

Providing wellness visits is not easy, but there are ways to make your practice more prepared. For example, a nurse or medical assistant could handle pre-visit planning to make the physician-led visit more efficient. 6 Another variation of the team-based model, which used a dedicated scheduler to contact Medicare patients about AWVs and then clinical pharmacists and licensed practical nurses to provide the visits, significantly increased use of preventive services. 7 It may also be worthwhile to set aside more time for these types of visits. While some visits can be completed in 30 to 40 minutes, more complicated encounters may take longer. Your EHR may also have templates and other tools available to make providing Medicare wellness visits more efficient, although the range of EHR capabilities is too wide to discuss here.

Regardless of how you schedule and perform these visits, you should recognize that Medicare wellness visits have great value in not only providing important preventive services to the patient but also closing quality measure gaps and contributing financial stability to a practice or organization.

Ganguli I, Souza J, McWilliams JM, Mehrotra A. Trends in use of the U.S. Medicare annual wellness visit, 2011–2014. JAMA . 2017;317(21):2233-2235.

Ganguli I, Souza J, McWilliams JM, Mehrotra A. Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit. Health Aff (Millwood) . 2018;37(2):283-291.

CMS. Annual wellness visit, including personalized prevention plan services. MLN Matters . March 2, 2016. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7079.pdf . Accessed Jan. 30, 2019.

CMS. Medicare Shared Savings Program: Quality Measure Benchmarks for the 2018 and 2019 Reporting Years, Guidance Document . December 2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/2018-and-2019-quality-benchmarks-guidance.pdf . Accessed Jan. 30, 2019.

CMS. Advance care planning. MLN Matters fact sheet. June 2018. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf . Accessed Jan. 30, 2019.

Cuenca AE. Making Medicare annual wellness visits work in practice. Fam Pract Manag . 2012;19(5):11-16.

Galvin SL, Grandy R, Woodall T, Parlier AB, Thach S, Landis SE. Improved utilization of preventive services among patients following team-based annual wellness visits. NC Med J . 2017;78(5):287-295.

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Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

Affordable Care Act Expands Medicare Coverage for Prevention and Wellness

September 9, 2010

The Affordable Care Act [1] (ACA) adds coverage for a new "Wellness Visit" and eliminates cost-sharing for almost all of the preventive services covered by Medicare, effective January 1, 2011. This Alert discusses both provisions.

Wellness Visit

Starting next year, Medicare will cover a new annual wellness visit and will provide payment for the creation of a personalized prevention plan. The wellness visit will include a health risk assessment to:

• Establish or update the individual's medical and family history;
• Create a list of current providers and suppliers involved in providing medical care, including a list of prescriptions;
• Take measurements of height, weight, body mass index, blood pressure and other routine measurements; and
• Detect cognitive impairments.

During the wellness visit, the health professional will establish or update a screening schedule for the next 5-10 years, based on recommendations of the United States Preventive Services Task Force (USPSTF). The recommendations of USPSTF are based on an individual's age and health status. The visit may include health education or preventive counseling services designed to reduce risk factors that have been identified during the visit. Examples of such education and counseling services include those designed to promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention and nutrition.

The wellness visit may be conducted by a physician or another practitioner whose services are recognized by Medicare. Such practitioners include physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, clinical social workers, and clinical psychologists. [2] Practitioners may also include health educators, registered dietitians, or nutrition professionals working under the supervision of a physician.

In proposed regulations to implement the new service, CMS listed "detection of any cognitive impairment" as one of the services to be included in the annual wellness visit. [3] However, CMS did not recommend yearly screenings for depression or for functional impairments, based on the findings of the USPSTF. The USPSTF states that the optimal interval for screening for depression in older individuals is unknown, although it does recognize that recurrent screening may be needed for certain patients.

The new annual wellness visit builds upon the current "Welcome to Medicare" check-up or "initial physical examination" that is available to beneficiaries within 12 months of their becoming covered under Medicare Part B. The initial preventive physical examination consists of a physical examination, including measurement of height, weight, and blood pressure and an electrocardiograph, with the goal of health promotion and disease detection. The initial preventive physical examination also includes education, counseling, and referral with respect to screening and other preventive services, although it does not include clinical laboratory tests. [4] A beneficiary is only entitled to a "Welcome to Medicare" check-up, and not a wellness visit exam, during the 12-month period after coverage begins under Part B. However, a beneficiary is entitled to personalized prevention plan services once a year thereafter.

Elimination of Cost-sharing for Preventive Services

As indicated in a previous Alert, ACA has eliminated cost-sharing for most of the preventive services already covered under Medicare, effective January 1, 2011. [5] The preventive services to which the provision applies are those that are appropriate for the individual and that are recommended with a grade of A or B by the USPSTF for any indication or population. The services for which no cost-sharing (deductible and/or co-payment) will be charged are:

• Mammograms every 12 months for eligible beneficiaries age 40 and older;
• Colorectal cancer screening, including flexible sigmoidoscopy or colonoscopy (see below);
• Cervical cancer screening, including a Pap smear test and pelvic exam;
• Cholesterol and other cardiovascular screenings;
• Diabetes screening;
• Medical nutrition therapy to help people manage diabetes or kidney disease;
• Prostate cancer screening (for most codes);
• Annual flu shot, pneumonia vaccine, and the hepatitis B vaccine;
• Bone mass measurement;
• Abdominal aortic aneurysm screening to check for a bulging blood vessel;
• HIV screening for people who are at increased risk or who ask for the test. [6]

Cost-sharing is also eliminated for the wellness visit and personal prevention plan.

CMS indicates that the following preventive services covered by Medicare are not recommended by USPSTF with a grade of A or B for any populations or indications, and will therefore continue to be subject to cost-sharing:

• Digital rectal examination furnished as a prostate cancer screening service;
• Glaucoma screening;
• Diabetes self-management training services;
• Barium enema furnished as a colorectal cancer screening. [7]

Note that, for all services, current coverage policies continue to apply. For example, Medicare only covers bone mass measurements once every two years for qualified high-risk individuals. [8] Testing within that time frame for people who meet the eligibility criteria will not be subject to a deductible or co-payment. Bone mass measurement will not be covered for someone who is not a high risk individual, however, regardless of the change in cost-sharing requirements.

Clarification Concerning Smoking Cessation Counseling

Coverage for smoking cessation counseling services became effective for services provided on or after August 25, 2010, the date of the recent CMS memorandum. Services may be provided on both an outpatient and an inpatient basis, but they are reimbursed under Medicare Part B. Smoking cessation counseling services provided before January 1, 2011, are subject to cost-sharing. Cost-sharing is eliminated for services provided after that date.

[1] Patient Protection and Affordable Care Act of 2010 (PPACA), Pub. L. 111-148 (March 23, 2010) §§4103, 4104.

[2] ACA § 4103 refers to practitioners described in 42 U.S.C. §1395u(b)(18)(C).

[3] 75 Fed. Reg. 40040, 40126 -40129 (July 13, 2010).

[4] 42 U.S.C. § 1395x(ww).

[5] https://www.medicareadvocacy.org/InfoByTopic/PartB/10_09.02.SmokingCessation.htm#_ftn1

[6] Fact Sheet: Benefits for Seniors of New Affordable Care Act Rules on Expanding Prevention Coverage, http://www.healthcare.gov/news/factsheets/pdf/07-14-10_prevention_seniors_fact_sheet.pdf .

[7] 75 Fed. Reg. 40040, 40129-40136 (July 13, 2010). The Federal Register includes a chart of the complete list of codes for preventive services that indicates whether the services are subject to cost-sharing both currently and starting in 2011.

[8] 42 U.S.C. 1395x

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What is Covered by Wellness Visit Under ObamaCare?

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Exactly what is and is not covered or to be discussed during a routine physical so as not to trigger additional charges?

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it’s July 2019 – is this still in effect for one annual physical and gynological exam a year with one free mammo a year? If so aren’t ALL plans/organizations covered by this law? HBCBS – under a Union Local 464? Please advise.

ObamaCareFacts.com

All plans do have this requirement aside from grandfathered plans. I think in some cases Union plans were able to skirt the requirements this to keep costs down (as were large employers)… although I think the reason was because most already offered these sorts of benefits (although we can see this is not true in this instance). You may want to check directly with them and ask, they would likely have the answer.

Vicki Royer

It may. it may. it may. it may,,,, but WHAT specifically DOES it cover? What specifically DOES it include? Seriously … the Bill was 3000 or 6000 pages long. How can it be so vague as the response above??????? My rating of this answer below IS a big fat 0.

You can see a full list of the preventative care that is covered under the Affordable Care Act, but as the answer noted, it largely depends on your provider using the correct billing codes for those procedures. There are also other criteria (like age, gender, and health history)for many of those preventative care services in order for them to be covered as necessary preventative care. The best way to ensure that a preventative measure will be covered before deductible is to call your insurance provider and ask them what billing codes and criteria they need the provider to use in order for it to be billed as a preventative service. Then provide that information to your doctor.

Tim McMullen

I, understand that if you bring up a problem, or have lab tests, you will be charged. You, will have to pay for labs, exrays ect. I feel, you might as well pay, your co-pay like I plan to. I, am not going to make an appointment for another day, afraid to ask a question. Obama are is stupid, if you can’t ask about, lets say, your thyroid or high blood pressure. I, have a Medicare suppement, and get extra help, yet I still pay a 35.00 co-pay, and am sure it will go up in 2017!!

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• v.8(4); 2017 Oct

The Effectiveness of Medicare Wellness Visits in Accessing Preventive Screening

Fabian camacho.

1 University of Virginia, Charlottesville, VA, USA

Nengliang (Aaron) Yao

Roger anderson.

Introduction: Under the American Affordable Care Act, Medicare insurance beneficiaries receive free Annual Wellness Visits (AWV); there is a need to examine the effectiveness of these visits. The purpose of this study is to examine their impact on subsequent screening rates. Methods: Using 2011-2014 Medicare FFS (fee-for-service) claims data, seven preventive care services, including vaccinations and cancer screenings were compared among beneficiaries who received and did not receive AWVs. Inverse probability treatment weights were used to achieve covariate balance between groups. Results: Nonrecipients were less likely to receive any of the 7 services compared with recipients of AWVs (63% vs 88%). The total number of services that the AWVs group received was 62% higher than nonrecipients. Subgroup analyses show that wellness visits were high across age groups, race/ethnic groups, rural/urban context, and counties of different economic development status. Conclusion: These results are consistent with the view that wellness visits improve screening rates and thus serve to reduce cancer burden.

Introduction

Under the Affordable Care Act (ACA), Medicare beneficiaries receive free coverage for Annual Wellness Visits (AWVs), which is a yearly office visit where the beneficiary can discuss the plan of preventive care for the coming year. During a visit, patients are evaluated with a Health Risk Assessment questionnaire, and may receive health advice, routine measurements, screening schedules, advance care planning, and other tasks related to prevention.

Prior research has found that the use of AWVs rose from about 7% (3.2 million visits) in 2011 to 20% (10.4 million visits) in 2016. 1 The utilization rates in 2016 vary from about 7% in Hawaii to 33% in Rhode Island. In 2014, The AWV utilization rates in non-Hispanic whites were 45% and 88% percent higher, respectively, than African Americans and Hispanics, and the rates in metropolitan residents were about 60% higher than rural residents. Medicare has reported that it spent about $1.2 billion on AWVs in 2016. 2

Few studies have examined the effectiveness of AWVs. Some researchers have argued that there is little benefit from annual examinations such as a physical examination, 3 but which differ from an AWV in that AWVs are not limited to physical health issues, and are instead guided by US Preventive Services Task Force (USPSTF) recommended preventive services. Others who have focused specifically on AWVs have found support for personalized prevention visits for all beneficiaries. 4 - 6 This study examines whether AWVs result in more recommended preventive care, on average and in racial/ethnic minorities and rural residents in Medicare fee-for-service (FFS) beneficiaries after Centers for Medicare and Medicaid Services adoption of ACA policies in 2011.

Study Data and Methods

We examined physician and outpatient claims of 2011-2014 for a sample drawn from approximately 3.18 million beneficiaries enrolled in Medicare 5% FFS, based on health care visit histories. To parse the effect of the AWV on follow-up screening from competing health care visit patterns, we were concerned that the follow-up rates may have been influenced by other previous visits or screening episodes (“S/P”) and which may have occurred sufficiently close to and prior to the wellness visit. Furthermore, the likelihood of a wellness visit may be influenced by the presence of these other visits or episodes, resulting in confounding bias. Thus to reduce bias, we conducted a stratified analysis by implementing a lookback period on patients with wellness visits (set at 90 days) to scan for the presence of S/P. Beneficiaries were classified into 3 groups: (1) those with initial/subsequent (G0438, G0439) wellness visit without indication of S/P during lookback period of 90 days, (2) those with wellness visits after S/P occurring during 90 days prior, and (3) control group with random reference date without S/P during 90 days prior or wellness visit at any time ( Figure 1 ). All beneficiaries were required to have at least 1 year FFS enrollment prior and post reference date with no indication of additional wellness visit during 365-day follow-up. For each candidate control, the reference date was selected at random among the available candidate months in order to diminish temporal and seasonal biases.

Five percent Centers for Medicare and Medicaid Services (CMS) sample selection.

Common screening event codes covered by Medicare during 2012-2013, including DTaP (diphtheria, tetanus, and acellular pertussis)/DTP/Td/influenza/pneumonia vaccinations, screening for cardiovascular disease, colorectal cancer, female breast cancer, prostate cancer, diabetes, and bone mass were then scanned in the Medicare physician services and outpatient files during 1 year after but not including reference date, with the objective of assessing the effect of wellness visit group on overall and individual screening rates. The HCPCS (Healthcare Common Procedure Coding System) codes used to identify screening and preventive services are shown in the appendix ; primary sources used to select the codes are described in the notes.

Because of the observational study design, rates may differ due to the effect of other confounders and not exclusively due to the group membership, resulting in biased comparisons. In order to correct for this type of bias, we weighed the sample using inverse probability weights for multiple groups (IPTW). 7 IPTW is comparable to propensity scoring but, by using suitable IPTW weights, the weighted sample among the 3 groups should have similar distributions of confounders, enabling a fair comparison between groups provided there is no hidden imbalance. A multinomial logistic regression was fit to the data in order to calculate the group membership probabilities needed for the weights. The covariates list used in the model included all possible 2-way interactions between the covariates in Figure 2 , excluding the comorbidities which were entered as main effects only. The quality of the IPTW weights was strengthened by the use of rescaling factor in order to reduce the presence of excessively large weights and their influence. Furthermore, the covariates balance among the groups was evaluated by assessing standardized differences scores. Confounders considered as predictors of membership and outcome consisted of beneficiary race (white, black, other), gender, age category at reference, Charlson comorbidity score (NCI Kablunde 2000 version 8 ), semester of reference date (2012-2013), National County Economic Distress from Appalachian Regional Commission 9 (2013 version), and NCHS rural urban 10 status from the Centers for Disease Control and Prevention. In addition, the broader set of individual comorbidity groups (n = 18) of the Charlson score were entered into the model as separate indicators in order to achieve balance by individual morbidities. Finally, accessibility to primary care at patient’s county centroid was also included as a potential confounder. This index was based on a 2-step floating catchment area method, 11 where the number of 2013 primary care providers at each county was extracted from the Area Health Resource File. 12

Unweighted covariate distributions.

As a secondary analysis, cumulative screening incidences for overall and individual screening rates were then compared also across groups using Kaplan-Meier failure curves. In addition, we performed subgroup analysis by economic distress, rurality, race, age, and Charlson index category in order to assess possible effect heterogeneity within disparity strata and discover potential differences which may contribute to literature relating wellness visits to disparities

Since covariate distributions by strata were not likely to be similar, we further assessed balance for each subgroup, adjusting for covariates with largest imbalances if needed. To assess differences between initial and subsequent wellness, a separate IPTW analysis was conducted comparing patients who were assigned to their initial wellness visit (G0438) vs patients who were assigned to a subsequent wellness visit (G0439). Next, in order to examine the effect of provider wellness visit volume on screening, we linked wellness visit providers after 2012 to wellness visit volumes from their Medicare Provider Utilization and Payment Data (MPUPD) and then conducted an IPTW analysis comparing beneficiary screening rates across provider volume quartiles. Finally, we conducted separate analysis with varying look-back period in order to assess the sensitivity of the results as a function of look-back period.

Limitations that the IPTW method may fail to address include the potential of hidden latent confounders which may result in a spurious association. These would include potential drivers of AVW use and preventive screening use which have not been controlled for. Sample limitations may affect the generalizability of the results. The beneficiaries in this sample are older Medicare beneficiaries who follow the distributions in Figure 2 , which may not be representative of the national population or a cohort of interest. Furthermore, the design of the study required fee for service Medicare restriction, which excludes effect of AWV under other types of plans and scenarios.

A total of 52 300 beneficiaries were included in the wellness visit only group (W), 20 850 were included in the wellness visit with prior S/P group (P + W), and 586 000 were included in the control group ( Figure 1 ). The majority of patients resided in middle ‘transitional” economic status counties (60%), lived in a metropolitan area (66%), were white (83%), slightly more female (53%), had a mean age of 70 years (SD = 13.1) with 19% age group ≤64 years, had no Charlson index defined comorbidities (68%), and had a most frequent comorbidity of diabetes (17%). Percentages varied between groups ( Figure 2 ), with noticeable differences being control age category ≤64 years (22% vs 11% other groups combined), and P + W group having more comorbidities (57% with 0 comorbidities vs 72%) and having more diabetes (24% vs 15%). After weighting the sample to match the control distribution, the maximum standardized difference balance diagnostic dropped from 0.35 to 0.02, resulting in relatively close rates between groups ( Figure 3 ).

Weighted covariate distributions.

Screening rates after follow-up for the control group were significantly lower compared with the other 2 groups ( Figure 4 ), with a mean of 1.19 different type of screening events (out of 7) compared to 1.68 in the wellness group and 1.99 in the P+W group. The confidence intervals, illustrated as error bars in Figure 4 , suggest the comparisons are highly significant (ie, P < .01), which is to be expected due to the large sample sizes. Additionally, control rates were significantly lower for all screening event types ( Figure 4 ). Overall, 63% of the control group had any one of the 7 screening events compared with 82% and 89% for the other 2 groups.

Screening events during 1-year follow-up.

Subgroup analysis ( Figure 5 ) showed the same difference and ordering of effects persisted in each subgroup examined, with some slight variations. A test of parallel trends across subgroups using statistical interaction tests rejected the hypothesis of parallel trends for all groups; this would be expected given the large sample sizes where even trivial differences may be significant. Some of the differences, however, are potentially interesting; for example, when comparing by Area Economic Distress, the control group (C) decreased from 1.27 to 1.09 with increasing levels of distress, whereas the wellness group (W) increased from 1.66 to 1.70, and the P + W group decreased from 2.04 to 1.96. This would suggest the wellness visits are serving to maintain screening rates in distressed areas compared to gradual decrease in controls.

Screening events by subgroups.

The cumulative incidence curves ( Figure 6 ) show the rates by time of follow-up, with rates at the end of one year matching up to the rates in Figure 2 . Wellness and preventive screening were consistently higher than the control group in all the charts. A visual classification of trends suggests 3 groups: those with ramp-up period after wellness visits (overall, colorectal cancer, bone mass, breast cancer), those without the ramp (vaccinations, diabetes), and an atypical pattern (CDS - cardiovascular disease screening, prostate). Although there are time periods in which the P + W groups experienced lower rates than the W group, ultimately, the P+W displays higher cumulative rates.

Cumulative incidence curves.

The comparison between Initial Wellness (G0438) versus Subsequent Wellness groups (G0439), conducted only in the wellness subgroups, standardizing to the covariate distribution of the initial G0438 wellness group, and adding the subgroup type in the predictive model to get IPTW weights, resulted in statistically indistinguishable rates (2.10 for both groups, P = .8698). The comparison of provider volume quartiles in subgroup with available volume information suggests an increase from 2.06 in the first quartile to 2.09 in the last quartile, with a difference of 0.03. This suggests increased volume associates with increased chance of screening, but relative increase is small.

To analyze the effect of varying lookback period, we extended from 90 days to 180 days and then 365 days. The sample sizes and covariate distributions of the groups change since increasing look-back restricts the pool of available observations to those of beneficiaries in the control (C) and wellness (W) group who did not experience any S/P during greater time periods. Without providing additional details, significant overall effects were still detected for the 180 days period (0.78 in controls vs 1.40 in W vs 1.89 in P + W) and the 365 days period (0.42 in controls vs 1.08 in W vs 1.80 in P + W). We attribute the decreasing rates to conducting the analysis on samples that are less likely to experience preventive visit and screening episodes.

Based on these results, screening rates are projected to significantly increase compared with control group for patients who have not received prior preventive care or screening episodes before AWV, either during the prior year or within a smaller time frame. That is, we find evidence in the study sample that AWV are modestly effective in increasing access to preventive services, including cancer screening among those not previously served. Ganjuli et al 1 have noted that early adoption of AWVs has been concentrated in Accountable Care Organizations and certain primary care physicians, suggesting patients who receive AWVs may tend to receive care from organizations and providers vested and motivated in preventive health practices. The fact that these same patients had higher receipt of preventive services within, presumably, the same organization or practice type, could suggest that the association between AWV and screening may be partially affected by increased prevention awareness leading to a policy of reimbursing for AWVs in addition to increased delivery of preventive services. Our findings reflect continuous enrollment in FFS during the study period, and thus do not capture results from managed care plans that may have been more prevention focused, so the association may be understated.

Patient-centric factors also play a role in determining choice of AWVs and screening practices. Findings here are consistent with AWVs being more likely to occur in metropolitan regions and regions with higher socioeconomic indices, along with individual characteristics such as white ethnicity, female gender, and older age groups. Taken together, the association of AWVs on receipt of preventive services observed in these results may be a function of genuine effect of AWV on screening, and potentially, patient factors which we sought to control thru IPTW analysis, as well as to a lesser degree (we hypothesize) unseen practice-driven factors that may affect both AWV and screening due to receiving care from organizations/ providers with a strong preventive care management and culture.

For the group of patients who received preventive services during the past year, AWV appears to likewise show a marked increase over control group, and are projected to experience higher screening rates than the AWV group, with disparity increasing as look-back period increases. The impact of AWV, however, may be reduced due to the influence of other preventive care/screening episodes during the past period on future period and presence of latent proactive factors in this group which may be contributing to the increase in rates. We surmise the hypothetical removal of AWV in this group may results in diminished rates but still be well above control rates.

Perhaps most important, if the strong associations observed here are accepted as fully or mostly genuine effects of AWV, AWVs may then be an important policy tool to reduce disparities in preventive services, such as cancer screenings and vaccinations, especially in disadvantaged groups which tend to lack prior preventive services. These groups include rural, low socioeconomic status, males, and African Americans populations. Policies to increase AWV penetration may involve increasing awareness of these visits with community health workers, proposing financial incentives, and increasing the willingness to schedule for these visits. Furthermore, AWVs may increase utilization of screenings and preventive services, not only because they raise awareness and motivate patients but also possibly because they motivate providers and raise their investment into their patients’ care. Thus, AWVs may also strengthen the therapeutic relationship between the patient and the provider, which in itself improves quality and outcomes of patient care.

Given the size of the screening effects found in this study together with the still sizeable underutilization of free AWV documented in other studies, 1 policies of no-cost access to AWVs, and their promotion to patient and practices could result in gains in early disease detection and improved health outcomes in the population through increased delivery of preventive services. At the very least, if increases in screening rates and disease prevention are desirable health care objectives, continuing a healthcare coverage of no-cost AWV begun by Affordable Care Act is highly warranted. In summary, given the benefits of AVW, there is a need for future research to determine effective community or practice-based interventions that increase use of AVWs in disadvantaged populations or patient groups.

Author Biographies

Fabian Camacho , MS, MA, is public health researcher with a background in biostatistical data analysis and data management of medical/public health databases particularly relating to patient centered health outcomes and associated risk factors in various medical conditions.

Nengliang (Aaron) Yao , PhD, is presently an assistant professor who specializes in health policy and administration issues around homebound cancer patients, as well as cancer prevention and control in the global context.

Roger Anderson , PhD, is presently a professor of public health sciences, director for population sciences and co-leader for cancer control and population health research. His work brings a population health perspective to cancer prevention, treatment and outcomes to the UVA Cancer Center to further its mission to improve the health and well-being of the population it serves.

Table of HCPCS Codes to identify Screening and Preventive Services.

• The source for “Other Preventive Visits” codes was the AMA CPT 2016 Manual.

• Primary source for vaccinations was from the CDC Immunization Information Systems (IIS): ( https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp )

• Primary source for other screening events was from the Medicare Learning Network Preventive Services Chart. ( https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html )

• CRC screening codes were supplemented with additional codes from KP Hedis Insight ( https://provider.ghc.org/open/providerCommunications/hedisInsight/index.jhtml )

• Breast cancer screening codes were supplemented with internal expert review.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Sec. 4103: Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan

This content, taken from the Affordable Care Act , is provided as a convenience.

(a) COVERAGE OF PERSONALIZED PREVENTION PLAN SERVICES.— (1) IN GENERAL.—Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (A) in subparagraph (DD), by striking ‘‘and’’ at the end; (B) in subparagraph (EE), by adding ‘‘and’’ at the end; and (C) by adding at the end the following new subparagraph: ‘‘(FF) personalized prevention plan services (as defined in subsection (hhh));’’. (2) CONFORMING AMENDMENTS.—Clauses (i) and (ii) of section 1861(s)(2)(K) of the Social Security Act (42 U.S.C. 1395x(s)(2)(K)) are each amended by striking ‘‘subsection (ww)(1)’’ and inserting ‘‘subsections (ww)(1) and (hhh)’’. (b) PERSONALIZED PREVENTION PLAN SERVICES DEFINED.—Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

‘‘Annual Wellness Visit ‘‘(hhh)(1) The term ‘personalized prevention plan services’ means the creation of a plan for an individual— ‘‘(A) that includes a health risk assessment (that meets the guidelines established by the Secretary under paragraph (4)(A)) of the individual that is completed prior to or as part of the same visit with a health professional described in paragraph (3); and ‘‘(B) that— ‘‘(i) takes into account the results of the health risk assessment; and ‘‘(ii) may contain the elements described in paragraph (2). ‘‘(2) Subject to paragraph (4)(H), the elements described in this paragraph are the following: ‘‘(A) The establishment of, or an update to, the individual’s medical and family history. ‘‘(B) A list of current providers and suppliers that are regularly involved in providing medical care to the individual (including a list of all prescribed medications). H. R. 3590—436 ‘‘(C) A measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements. ‘‘(D) Detection of any cognitive impairment. ‘‘(E) The establishment of, or an update to, the following: ‘‘(i) A screening schedule for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force and the Advisory Committee on Immunization Practices, and the individual’s health status, screening history, and age-appropriate preventive services covered under this title. ‘‘(ii) A list of risk factors and conditions for which primary, secondary, or tertiary prevention interventions are recommended or are underway, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (as described under subsection (ww)(1)), and a list of treatment options and their associated risks and benefits. ‘‘(F) The furnishing of personalized health advice and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote selfmanagement and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition. ‘‘(G) Any other element determined appropriate by the Secretary. ‘‘(3) A health professional described in this paragraph is— ‘‘(A) a physician; ‘‘(B) a practitioner described in clause (i) of section 1842(b)(18)(C); or ‘‘(C) a medical professional (including a health educator, registered dietitian, or nutrition professional) or a team of medical professionals, as determined appropriate by the Secretary, under the supervision of a physician. ‘‘(4)(A) For purposes of paragraph (1)(A), the Secretary, not later than 1 year after the date of enactment of this subsection, shall establish publicly available guidelines for health risk assessments. Such guidelines shall be developed in consultation with relevant groups and entities and shall provide that a health risk assessment— ‘‘(i) identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs of the individual; and ‘‘(ii) may be furnished— ‘‘(I) through an interactive telephonic or web-based program that meets the standards established under subparagraph (B); ‘‘(II) during an encounter with a health care professional; ‘‘(III) through community-based prevention programs; or ‘‘(IV) through any other means the Secretary determines appropriate to maximize accessibility and ease of use by beneficiaries, while ensuring the privacy of such beneficiaries. ‘‘(B) Not later than 1 year after the date of enactment of this subsection, the Secretary shall establish standards for interactive telephonic or web-based programs used to furnish health risk assessments under subparagraph (A)(ii)(I). The Secretary may utilize any health risk assessment developed under section 4004(f) of the Patient Protection and Affordable Care Act as part of the requirement to develop a personalized prevention plan to comply with this subparagraph. ‘‘(C)(i) Not later than 18 months after the date of enactment of this subsection, the Secretary shall develop and make available to the public a health risk assessment model. Such model shall meet the guidelines under subparagraph (A) and may be used to meet the requirement under paragraph (1)(A). ‘‘(ii) Any health risk assessment that meets the guidelines under subparagraph (A) and is approved by the Secretary may be used to meet the requirement under paragraph (1)(A). ‘‘(D) The Secretary may coordinate with community-based entities (including State Health Insurance Programs, Area Agencies on Aging, Aging and Disability Resource Centers, and the Administration on Aging) to— ‘‘(i) ensure that health risk assessments are accessible to beneficiaries; and ‘‘(ii) provide appropriate support for the completion of health risk assessments by beneficiaries. ‘‘(E) The Secretary shall establish procedures to make beneficiaries and providers aware of the requirement that a beneficiary complete a health risk assessment prior to or at the same time as receiving personalized prevention plan services. ‘‘(F) To the extent practicable, the Secretary shall encourage the use of, integration with, and coordination of health information technology (including use of technology that is compatible with electronic medical records and personal health records) and may experiment with the use of personalized technology to aid in the development of self-management skills and management of and adherence to provider recommendations in order to improve the health status of beneficiaries. ‘‘(G)(i) A beneficiary shall only be eligible to receive an initial preventive physical examination (as defined under subsection (ww)(1)) at any time during the 12-month period after the date that the beneficiary’s coverage begins under part B and shall be eligible to receive personalized prevention plan services under this subsection provided that the beneficiary has not received such services within the preceding 12-month period. ‘‘(ii) The Secretary shall establish procedures to make beneficiaries aware of the option to select an initial preventive physical examination or personalized prevention plan services during the period of 12 months after the date that a beneficiary’s coverage begins under part B, which shall include information regarding any relevant differences between such services. ‘‘(H) The Secretary shall issue guidance that— ‘‘(i) identifies elements under paragraph (2) that are required to be provided to a beneficiary as part of their first visit for personalized prevention plan services; and ‘‘(ii) establishes a yearly schedule for appropriate provision of such elements thereafter.’’. (c) PAYMENT AND ELIMINATION OF COST-SHARING.— (1) PAYMENT AND ELIMINATION OF COINSURANCE.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (A) in subparagraph (N), by inserting ‘‘other than personalized prevention plan services (as defined in section 1861(hhh)(1))’’ after ‘‘(as defined in section 1848(j)(3))’’; (B) by striking ‘‘and’’ before ‘‘(W)’’; and (C) by inserting before the semicolon at the end the following: ‘‘, and (X) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848’’. (2) PAYMENT UNDER PHYSICIAN FEE SCHEDULE.—Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting ‘‘(2)(FF) (including administration of the health risk assessment) ,’’ after ‘‘(2)(EE),’’. (3) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS.— (A) EXCLUSION FROM OPD FEE SCHEDULE.—Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking ‘‘and diagnostic mammography’’ and inserting ‘‘, diagnostic mammography, or personalized prevention plan services (as defined in section 1861(hhh)(1))’’. (B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended— (i) in subparagraph (F), by striking ‘‘and’’ at the end; (ii) in subparagraph (G)(ii), by striking the comma at the end and inserting ‘‘; and’’; and (iii) by inserting after subparagraph (G)(ii) the following new subparagraph: ‘‘(H) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(X),’’. (4) WAIVER OF APPLICATION OF DEDUCTIBLE.—The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended— (A) by striking ‘‘and’’ before ‘‘(9)’’; and (B) by inserting before the period the following: ‘‘, and (10) such deductible shall not apply with respect to personalized prevention plan services (as defined in section 1861(hhh)(1))’’. (d) FREQUENCY LIMITATION.—Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended— (1) in paragraph (1)— (A) in subparagraph (N), by striking ‘‘and’’ at the end; (B) in subparagraph (O), by striking the semicolon at the end and inserting ‘‘, and’’; and (C) by adding at the end the following new subparagraph: ‘‘(P) in the case of personalized prevention plan services (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’’; and (2) in paragraph (7), by striking ‘‘or (K)’’ and inserting ‘‘(K), or (P)’’. (e) EFFECTIVE DATE.—The amendments made by this section shall apply to services furnished on or after January 1, 2011. in this title’’ and inserting ‘‘not described in subparagraph

(A) or (C) of paragraph (3)’’; and (3) by adding at the end the following new paragraph: ‘‘(3) The term ‘preventive services’ means the following: ‘‘(A) The screening and preventive services described in subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection). ‘‘(B) An initial preventive physical examination (as defined in subsection (ww)). ‘‘(C) Personalized prevention plan services (as defined in subsection (hhh)(1)).’’. (b) COINSURANCE.— (1) GENERAL APPLICATION.— (A) IN GENERAL.—Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is amended— (i) in subparagraph (T), by inserting ‘‘(or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual)’’ after ‘‘80 percent’’; (ii) in subparagraph (W)— (I) in clause (i), by inserting ‘‘(if such subparagraph were applied, by substituting ‘100 percent’ for ‘80 percent’)’’ after ‘‘subparagraph (D)’’; and (II) in clause (ii), by striking ‘‘80 percent’’ and inserting ‘‘100 percent’’; (iii) by striking ‘‘and’’ before ‘‘(X)’’; and (iv) by inserting before the semicolon at the end the following: ‘‘, and (Y) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part’’. (2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS.— (A) EXCLUSION FROM OPD FEE SCHEDULE.—Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. H. R. 3590—440 1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is amended— (i) by striking ‘‘or’’ before ‘‘personalized prevention plan services’’; and (ii) by inserting before the period the following: ‘‘, or preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population’’. (B) CONFORMING AMENDMENTS.—Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)), as amended by section 4103(c)(3)(B), is amended— (i) in subparagraph (G)(ii), by striking ‘‘and’’ after the semicolon at the end; (ii) in subparagraph (H), by striking the comma at the end and inserting ‘‘; and’’; and (iii) by inserting after subparagraph (H) the following new subparagraph: ‘‘(I) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and are furnished by an outpatient department of a hospital and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount determined under paragraph (1)(W) or (1)(Y),’’. (c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE SERVICES AND COLORECTAL CANCER SCREENING TESTS.—Section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended by section 4103(c)(4), is amended— (1) in paragraph (1), by striking ‘‘items and services described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive services described in subparagraph (A) of section 1861(ddd)(3) that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual.’’; and (2) by adding at the end the following new sentence: ‘‘Paragraph (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.’’. (d) EFFECTIVE DATE.—The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.

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Medicare for Professionals

The medicare annual wellness visit: opportunities for the aging network.

Jun 15, 2022

15 min read

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Kathleen Cameron

Senior Director of NCOA's Center for Healthy Aging

Ann Kayrish

Senior Program Manager, for Medicare

Key Takeaways

Medicare’s free Welcome to Medicare and Annual Wellness Visits are preventive services aimed at addressing a range of health concerns such as depression, cognitive impairment, and fall risk.

Introduced in 2011 as part of the Affordable Care Act, the Medicare Annual Wellness Visit has not realized its full potential to address the preventive health care needs of older adults.

The Aging Network could provide a range of services to improve the Medicare Annual Wellness Visit, including Medicare beneficiary awareness and education, receiving referrals from local health care providers, and providing supportive services for needs identified through the visits.

Providing preventive health care to older adults is more critical now than ever, considering the impact of the pandemic on older adults and those with chronic illness and/or physical disabilities. And the Annual Wellness Visit (AWV) benefit through Medicare is an important but under-used component of preventive health for Medicare beneficiaries.

The Aging Network can play a vital role to address barriers to AWV access, especially for minority and underserved older adults.

What are Medicare Annual Wellness Visits?

Introduced as part of the Affordable Care Act, Medicare AWVs are designed to provide health promotion and preventive care to Medicare beneficiaries and are an important strategy in addressing a range of issues that significantly impact quality of life such as such as depression, cognitive impairment, and fall risk. Yet Medicare AWV policy and inherent limitations have meant this benefit has failed to realize its potential and address the preventive health needs of older adults.

The reality of incorporating those wellness visits into clinical practice poses challenges for health care providers, given the time constraints and other pressing health concerns for older patients.

How can the Aging Network improve use of the Annual Wellness Visit?

Area agencies on aging, community-based organizations, and others in the Aging Network are well-poised to expand access to and use of the AWV. The network can:

• Deliver education and awareness
• Provide supportive services
• Conduct all or part of the health risk assessment
• Accept referrals for social services that address unmet needs. Community-based organizations  can also provide follow-up for needed services from health care providers conducting the AWV.

Developed in partnership with the USAging’s Aging and Disability Business Institute through a grant from the John A. Hartford Foundation, "The Annual Wellness Visit: Opportunities for the Aging Network" policy spotlight describes Medicare’s Wellness Visits, current approaches to provide this benefit to Medicare beneficiaries, challenges related to access and opportunities for the Aging Network. This brief also presents policy and programmatic recommendations to improve uptake and effectiveness of wellness visits and an enhanced role for the Aging Network.

What other changes could expand access to the Medicare Annual Wellness Visit?

As policymakers consider improvements to Medicare, an expanded role for the Aging Network related to the AWV should be part of the conversation. NCOA also recommends several policy and regulatory changes to reduce barriers to AWV access, including:

• Allowing the Annual Wellness Visit to be conducted without direct physician oversight
• Extending telehealth benefits under Medicare
• Incorporating a screening for the social determinants of health (SDOH) in the Annual Wellness Visit and including a modest bonus payment or increased reimbursement to providers who conduct the SDOH screening
• Strengthening standards and requirements fo rscreenings and referral protocols for home and community-based services such as nutrition, evidence-based health promotion and disease prevention programs, and transportation
• Collecting data and conducting oversight to track and better ensure compliance with statutory requirements that health risk assessments meet hte guidelines established by the secretary of health and human services
• Supporting an evaluation conducted by the Centers for Medicare and Medicaid Services (CMS) Innovation Center, or another entity, of current practices and how to improve access to and effectiveness of the Medicare Annual Wellness Visit

NCOA will continue to advocate for needed changes to the AWV to reduce barriers to access and for increased opportunities for the Aging Network to partner with health care providers through contracts and reimbursement for services related to the AWV.

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Health and Human Services secretary visits Allentown, discusses Hispanic health care, Obamacare and prescription drug costs

U .S. Department of Health and Human Services Secretary Xavier Becerra was in the Lehigh Valley on Monday to tour hospitals, tout HHS accomplishments and do some work in a nonofficial capacity for President Joe Biden’s reelection campaign.

During his visit, Becerra was joined by U.S. Rep. Susan Wild and Allentown Mayor Matt Tuerk as he toured St. Luke’s University Health Network’s OB/GYN Care Associates in Allentown, a fully Spanish-speaking practice, and the Star Community Wellness Center. Amid all that, Becerra, Wild and Tuerk participated in roundtable discussions in the morning and at noon and a news conference in the afternoon.

Issues like the Inflation Reduction Act’s changes to prescription drug costs for Medicare recipients, the 14th anniversary of the Affordable Care Act, and Hispanic health care were major topics of discussion.

On the Affordable Care Act, Becerra touted how a record 300 million Americans now have health insurance, 21.4 million of whom have plans through marketplaces established under the health care law.

Becerra and Wild also touched on the work that has been done to lower health care costs and cap insulin at $35 a month for seniors on Medicare through the Inflation Reduction Act. Starting next year, the Inflation Reduction Act caps total prescription drug costs for seniors with Medicare at $2,000 a year.

The quality of care available to Allentown’s sizable Hispanic and Latino population was also a topic of discussion. Becerra, who is Hispanic, praised what he saw at St. Luke’s and Star Community Wellness for their commitments to the Lehigh Valley’s Hispanic community.

“When people come into facilities to get their service, they’re going to be treated with great respect,” he said. “So much so that they can speak to the health professionals in their language. They have health professionals that will service them and understand their not just linguistic but cultural needs.

“It then should not surprise you some of the health care results that you’re seeing,” Becerra said. “The diabetes rate is lower in many respects among some of the population here, even though in Latinos diabetes is very prevalent, lower rates because people are probably getting very good services and treatment here.”

At a separate lunch meeting at Allentown restaurant La Cocina del Abuelo, Becerra — acting not in his official capacity as secretary, but as an advocate for Biden’s reelection campaign — met with Latino leaders and business owners to discuss the November presidential race.

Becerra asked the roundtable for feedback and suggestions on how the Biden campaign can reach out to Latino voters.

“We are not monolithic thinkers. It’s not one size fits all,” said Guillermo Lopez, a Bethlehem native and owner of a diversity, equity and inclusion firm. “We have conservatives, we have liberals, we have everything in between. But more importantly, we want our families to be healthy, safe and be able to work hard to move forward. I think it’s the kitchen-table issues that matter most.”

In an interview following the roundtable, Becerra touted Biden’s commitment to Latino voter outreach.

“We want to recognize that the Latino community sometimes feels like politicians don’t pay attention,” Becerra said. “President Biden wants to focus on Allentown, including Latinos in Allentown.”

©2024 The Morning Call. Visit mcall.com. Distributed by Tribune Content Agency, LLC.

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HHS Finalizes Policies to Make Marketplace Coverage More Accessible and Expand Essential Health Benefits

Today, the Biden-Harris Administration, through the U.S. Department of Health and Human Services (HHS)’s Centers for Medicare & Medicaid Services (CMS), announced policies for the Affordable Care Act Marketplaces that make it easier for low-income people to enroll in coverage, provides states the ability to increase access to routine adult dental services, and sets network adequacy standards for the time and distance people travel for appointments with in-network providers. Finally, the rule will standardize certain operations across the Marketplaces to increase reliability and consistency for consumers. The 2025 Notice of Benefit and Payment Parameters final rule builds on the Administration’s previous work expanding access to quality, affordable health care and raising standards for Marketplace plans nationwide.

“More than 21 million Americans signed up for high-quality, affordable health care coverage through the ACA Marketplaces in 2024. We want to build on this success to make Marketplace plans even better,” said HHS Secretary Xavier Becerra. “This rule will allow coverage of routine dental benefits for the first time, expand requirements to ensure reliable access to health care providers, and ensure consumers with lower incomes can sign up for coverage when they need it.”

“Access to affordable, quality health care options remain a concern across the country and a top priority for CMS,” said CMS Administrator Chiquita Brooks-LaSure. “This rule includes groundbreaking ways to access health care services - such as addressing barriers for routine adult dental coverage for the first time and including considerations for how far people travel to see a health care provider. At CMS, we continue to explore ways to help Americans access high-quality coverage through the ACA Marketplaces.”

Increasing Access to Health Care Services Adult Dental Services

CMS has expanded access to dental benefits by finalizing measures to allow states the option to add routine adult dental services as an essential health benefit (EHB). For the first time, and starting on January 1, 2027, every state will be able to update their EHB-benchmark plans to include routine non-pediatric dental services, such as cleanings, diagnostic X-rays, and restorative services like fillings and root canals, through the EHB-benchmark application process beginning in 2025. 

Network Adequacy 

The final rule creates more consistent, nationwide standards on how far and how long a consumer must travel to see various types of providers in State Marketplaces and State-based Marketplaces on the Federal Platform (SBM-FPs). State Marketplaces and State-based Marketplaces must review a plan’s network information prior to certifying any plan as a qualified health plan (QHP), consistent with the reviews conducted by the Federally-facilitated Marketplaces (FFMs). 

Making It Easier to Enroll in Coverage Special Enrollment Periods

The rule extends the special enrollment period (SEP) for consumers with household incomes at or below 150% of the FPL (for the 2025 plan year, $38,730 for a family of three) to enroll in coverage in any month rather than only during Open Enrollment. Previously, this SEP was only available when enhanced subsidies under the IRA were available. 

The rule also aligns the dates of Open Enrollment periods across almost all Marketplaces to generally begin on November 1 and end no earlier than January 15, with the option to extend the Open Enrollment period beyond January 15. 

Additionally, the rule aims to prevent coverage gaps for those transitioning between different Marketplaces or from other insurance coverage by allowing those selecting coverage during certain SEPs to receive coverage beginning the first day of the month after the QHP is selected, as opposed to coverage beginning at a later date if the consumer enrolls between the 15th and the end of the month.

Streamlining the Enrollment Process  This rule includes multiple policies to standardize operations among the Federally-facilitated and State-based Marketplaces to ensure a more streamlined consumer experience, such as requiring Marketplaces to have live call center representatives available during call center hours of operation to assist consumers with QHP application submission and enrollment, generally holding Open Enrollment from November 1-January 15 (with the option for Marketplaces to extend Open Enrollment to a later date), and automatically re-enrolling people who are enrolled in a catastrophic plan for the next year, in order to prevent gaps in coverage.

For more information on the final rule, see the fact sheet at  https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2025-final-rule

Click here to view the final rule:  https://www.cms.gov/files/document/cms-9895-f-patient-protection-final.pdf

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