MLN Educational Tool: Knowledge, Resources, Training


When can CMS add new preventive services as Medicare benefits?

CMS may add preventive services coverage through the National Coverage Determination (NCD) process if the service meets all criteria:

  1. Reasonable and necessary for the prevention or early detection of illness or disability
  2. Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF)
  3. Appropriate for individuals entitled to benefits under Part A or enrolled under Medicare Part B

CMS may also add additional preventive services through statutory and regulatory authority.

For more preventive services information, refer to the USPSTF Published Recommendations and the Medicare Preventive Services Announcements webpages.

What is a primary care setting?

A primary care setting is defined as one where clinicians deliver integrated, accessible health care services, accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Medicare doesn't consider emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices as primary care settings under this definition.

How do I determine the last date a patient got a preventive service so I know the patient is eligible to get the next service and the service won't be denied due to frequency edits?

You have different options for accessing eligibility information. You may access the information through the CMS HIPAA Eligibility Transaction System (HETS) either directly or through your eligibility services vendor, through your MAC provider call center Interactive Voice Response (IVR) unit, or through the MAC provider web portal. Contact your eligibility service vendor or contact your MAC.

My patients don't follow up on routine preventive care. How can I help them remember when they're due for their next preventive service?

Medicare offers a Preventive Services Checklist for your patients so they can track their preventive services.



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