Some big changes to Medicare in 2013

By David Sayen

Gazette Contributor

The Affordable Care Act strengthened Medicare in important ways. Signed in 2010, the federal health law already has provided free preventive health benefits to millions of people with Medicare, and saved billions of dollars for those who hit the gap in their Part D prescription drug coverage.

In 2013, discounts on prescription drugs for people who reach the Part D “donut hole” will increase, and Medicare will cover screenings and counseling for alcohol misuse, behavioral therapy for cardiovascular disease, counseling for obesity, and more.

If you reach the donut hole in 2013, you’ll pay only 47.5% for covered brand-name drugs and 79% for generic drugs. Thanks to the Affordable Care Act, these discounts will gradually increase until the hole is closed in 2020.

In 2013, Medicare will cover one alcohol misuse screening per year for adults with Medicare (including pregnant women) who use alcohol, but don’t meet the medical criteria for alcohol dependency.

If your primary-care doctor or other primary-care practitioner determines you’re misusing alcohol, you can get up to four face-to-face counseling sessions per year (if you’re competent and alert during counseling). A qualified primary-care doctor or other primary-care practitioner must provide the counseling in a primary-care setting such as a doctor’s office.

Medicare also will cover one visit per year with your primary-care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss whether taking aspirin is appropriate for you, check your blood pressure, and give you tips to make sure you’re eating well.

If you have a body mass index of 30 or more, Medicare will cover intensive counseling to help you lose weight. This counseling may be covered if you get it in a primary-care setting, where it can be coordinated with your personalized prevention plan.

In 2013, Medicare also will cover screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for people with Medicare who are pregnant and/or at increased risk for sexually transmitted infection. Medicare covers these tests once every 12 months or at certain times during pregnancy.

In addition, Medicare covers up to two high-intensity behavioral counseling sessions each year for sexually-active adults at increased risk for sexually transmitted infections. Medicare covers this counseling only in a primary-care setting. Counseling in an inpatient setting, like a skilled nursing facility, isn’t covered as a preventive service.

You pay nothing for any of the above services if your primary-care doctor or other qualified primary-care practitioner accepts Medicare’s payment amount. 

Medicare now covers one depression screening per year, too. The screening must be done in a primary-care setting that can provide follow-up treatment and referrals. You pay nothing for this test if the doctor or other qualified provider accepts Medicare payment, but you generally have to pay 20% of the Medicare‑approved amount for the doctor’s visit.

Besides these services, Medicare covers a long list of preventive benefits – often at no cost to you – to help you stay healthy and detect disease in its most treatable stages.

Medicare-covered preventive services include tests and screenings for breast, prostate, cervical, and colon cancer; screenings for conditions that may trigger heart attack or stroke; checks for diabetes and glaucoma; and counseling to help you stop smoking.

You’re also entitled to a one-time “Welcome to Medicare” checkup during the first 12 months after you take Medicare Part B, and wellness visits with your doctor each year after that. These visits are free.

Shots to protect you against flu and pneumonia also are free.

The Affordable Care Act eliminated deductibles and co-pays for most Medicare preventive services in order to encourage people to use them more.

Please take advantage of them!

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).