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Medicare Guidelines


Annual Wellness Visit

Preventive Services - Health Care Reform


Previous Law

In addition to a number of specific preventive services enumerated in law, Medicare covers a one-time initial preventive physical examination (IPPE), with no deductible. The IPPE is reimbursable only if provided within one year of Medicare Part B enrollment. Medicare does not otherwise cover periodic routine health examinations.

The United States Preventive Services Task Force (USPSTF), administered by the Health and Human Services Agency for Healthcare Research and Quality (AHRQ), is an independent panel of private-sector experts in primary care and prevention that assesses scientific evidence of the effectiveness of clinical preventive services, including screening, counseling, and preventive medications. It provides evidence-based recommendations for the use of preventive services, which may vary depending on age, gender, and risk factors for disease, among other considerations. Services are given a rating of A, B, C, D or I. Services rated A or B are recommended. For services rated C, USPSTF makes no recommendation for or against their routine use. For services rated D, USPSTF recommends against routinely providing the service to asymptomatic patients, based on evidence that the service is not beneficial and may be harmful. Finally, services rated I are deemed to have insufficient evidence to recommend for or against their routine use.


Committee Bill and Present

Beginning in 2011, Medicare would cover an annual wellness visit and personalized prevention plan services. Such services would include a comprehensive health risk assessment, to be completed prior to or as part of a visit with a health professional. Health professionals authorized to conduct such a visit would be physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, other medical professionals (including health educators, registered dietitians, or nutrition professionals), or a team of medical professionals, as determined appropriate by the Secretary, under the supervision of a physician.

The personalized prevention plan would take into account the findings of the health risk assessment and include the following required elements: review and update of medical and family history; a five- to ten-year screening schedule and referral for services recommended by USPSTF; a list of identified risk factors and conditions and a strategy to address them; a list of all medications currently prescribed and all providers regularly involved in the patient's care; health advice and referral to education and preventive counseling or community-based interventions to address modifiable risk factors such as weight, physical activity, smoking, and nutrition; measurement of height, weight, body mass index (or waist circumference, if appropriate), and blood pressure; and other elements determined appropriate by the Secretary. Optional elements could include review or referral for testing and treatment of possible chronic conditions, a cognitive impairment assessment, and administration of or referral for appropriate Medicare-covered immunizations and screening tests, among others.

Within one year of enactment, the Secretary would be required to publish guidelines for health risk assessments and a health risk assessment model. Guidelines would identify chronic diseases, modifiable risk factors, and urgent health needs. The assessment could be provided through an interactive telephonic or web-based program, during an encounter with a health professional, or through other means established by the Secretary. The Secretary would be required to set standards for the electronic tools that could be used to deliver the assessment, take steps to make beneficiaries and providers aware of the need to conduct such assessment prior to or in conjunction with receipt of the personalized prevention plan service; and encourage the use of appropriate health information technology in carrying out these activities.

All enrolled beneficiaries would be eligible for the wellness visit once every year. No co-payment or deductible would apply. The Secretary would be required to issue guidance regarding the frequency at which specific elements of the plan must be furnished. During the first year of Part B enrollment, beneficiaries could receive either the IPPE or the personalized prevention plan service, but not both. All required and optional plan elements must be covered for the first personalized prevention plan visit.

The amendments made by this section would apply to services furnished on or after January 1, 2011.