MLN Educational Tool: Knowledge, Resources, Training

Frequently Asked Questions (FAQs)

When can CMS add new preventive services as Medicare benefits?

CMS may add coverage of preventive services through the National Coverage Determination (NCD) process if the service meets all of the following 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 Part B of the Medicare Program

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

Visit the USPSTF Published Recommendations and the Medicare Preventive Services Announcements webpages for information on preventive services.

What is a primary care setting?

A primary care setting is defined as one that provides integrated, accessible health care services by clinicians who are 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. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices are not considered primary care settings under this definition.

How do I determine the last date a Medicare beneficiary got a preventive service so I know the beneficiary is eligible to get the next service and the service will not 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 Medicare Administrative Contractor (MAC) provider call center Interactive Voice Response (IVR) unit, or through the MAC provider web portal. Contact your eligibility service vendor or check with your MAC’s eligibility services for more information.

My patients do not follow up on routine preventive care. How can I help them remember when they are due for their next preventive service?

Medicare provides a Preventive Services Checklist you can give your patients so they can track their preventive services.



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