Health Maintenance Guidelines^1,2

¹ Includes medical/social history review, depression screen, functional ability and safety screen, height, weight, BMI, blood pressure, visual acuity screen, end-of-life planning, optional screening EKG, and education, counseling, and referral for other Medicare covered preventive services as appropriate.

² Services that need to be performed more frequently than stated due to specific health needs of the Member and that would be considered medically necessary may be eligible for coverage when submitted with the appropriate diagnosis and procedure(s) and are covered under the core medical benefit.

³ The Routine Hearing Test remains as the only intervention which is provided in excess of traditional Medicare Part B coverage (see below, footnote #13).

⁴ Members with one of the following are eligible: hypertension, dyslipidemia, obesity (BMI > 30), or prior diagnosis of elevated impaired fasting glucose or glucose intolerance. Members with two of the following are also eligible: overweight (BMI > 25 but < 30), family history of diabetes, age 65 years or older, or personal history of gestational diabetes or giving birth to a baby weighing > 9 pounds.

⁵ High-risk criteria are: a family history of glaucoma; or personal history of diabetes; or African-American age 50 and older; or Hispanic-American age 65 and older.

⁶ Members with any of the following are eligible: estrogen-deficient female Members at risk for osteoporosis, Members with certain spinal abnormalities evident by x-ray, Members receiving (or expected to get) long-term (more than 3 months) corticosteroid therapy, Members with primary hyperparathyroidism, or Members being monitored to assess the response to FDA-approved osteoporosis drug therapy.

⁷ For guaiac-based testing, six stool samples are obtained (2 samples on each of 3 consecutive stools, while on appropriate diet, collected at home). For immunoassay testing, specific manufacturer’s instructions are followed.

⁸ High-risk criteria are: a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; or a family history of familial adenomatous polyposis; or a family history of hereditary nonpolyposis colorectal cancer; or a personal history of adenomatous polyps; or a personal history of colorectal cancer; or a personal history of inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

⁹ Covered as an alternative to either a screening flexible sigmoidoscopy or a screening colonoscopy.

¹⁰ According to current guidelines set forth by the Centers for Disease Control and Prevention (CDC), PCV13 is intended to be the initial vaccine and PPSV23 the second vaccine. However, prior pneumococcal vaccination history should be taken into consideration, as the reverse order may sometimes be justified. Receiving multiple vaccinations of the same vaccine type is not generally recommended.

¹¹ Capital Blue Cross considers Members to be “high risk” in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC) 

¹² Covered screenings are for Chlamydia, gonorrhea, syphilis and/or Hepatitis B. Recommendations for screening of pregnant women are too detailed for inclusion here – refer to Centers for Medicare & Medicaid Services (CMS)

¹³ Increased risk criteria are based upon US Preventive Services Task Force (USPSTF) guidelines and include any Medicare beneficiary who asks for the testing 

¹⁴ High-risk criteria are: women with a high risk for developing cervical or vaginal cancer or those of childbearing age with an abnormal Pap test within past 3 years.

¹⁵ This intervention is provided in excess of traditional Medicare Part B coverage but it is not a covered benefit for all Capital Blue Cross Medicare options. [Excluded from this extra benefit are Capital Blue Cross Medicare Essential HMO and Capital Blue Cross Medicare Classic PPO.]

¹⁶ Continued high-risk: Members who have had continued illicit injection drug use since the prior negative screening test.

¹⁷ Initial/subsequent lung cancer screening visits and written orders for eligible LDCT scans require certain medical record elements, which are too detailed for inclusion here – refer to Centers for Medicare & Medicaid Services (CMS) 

¹⁸ High-risk is defined as persons born in countries and regions with a high prevalence of hepatitis B virus (HBV) infection (i.e., > 2%), US-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection (i.e., > 8%), HIV-positive persons, men who have sex with men, injection drug users and household contacts or sexual partners of persons with HBV infection. Continued high-risk refers to men who have sex with men, injection drug users and household contacts or sexual partners of persons with HBV infection AND who do not receive hepatitis B vaccination.

¹⁹ ACP must be performed by the same provider on the same date as a paid AWV to be considered as a preventive service.

²⁰ MDPP fact sheet about Member eligibility and MDPP search tool for participating providers/organizations

Reference Sources: Centers for Medicare & Medicaid Services; Novitas Solutions; Centers for Disease Control and Prevention (CDC)