Medicare Member InformationMember NamePhoneEmail IDDOBGenderMaleFemalePart A Coverage Start DatePart B Coverage Start Date Info Quick Info Why We Ask for This Info Medicare pays for many preventive services to help keep you healthy. These services can detect health problems early, when treatment works best. The Five-Year Road Map is an educational tool designed to help you understand which Medicare-covered preventive services you may be eligible for over the next five years. It’s based on the official CMS booklet, Your Guide to Medicare Preventive Services (2025 edition), and follows Medicare's rules based on your age, gender, risk factors, and Part A and B start dates. Yes. All people with Medicare can get a “Welcome to Medicare” preventive visit. Important: This tool is for informational use only and is not affiliated with or endorsed by the Centers for Medicare & Medicaid Services (CMS) or any government agency. It doesn’t replace medical advice. Your doctor may recommend services that Medicare doesn’t cover or suggest a different schedule than Medicare allows. Your Road Map estimates when each service is likely due based on Medicare guidelines. Actual eligibility and coverage may vary. Always consult your provider to decide what’s right for your personal health needs General DetailsOne Time "Welcome To Medicare" Preventive Visit Exam.Have You Had Your Welcome To Medicare Exam?YesNoMedicare Exam Date Info Quick Info The “Welcome to Medicare” preventive visit isn’t a physical exam. Medicare covers a “Welcome to Medicare” preventive visit. This visit is a great way to get up-to-date on important screenings and shots and to talk with your doctor or other health care provider about your family history and how to stay healthy Am I covered? Yes. All people with Medicare can get a “Welcome to Medicare” preventive visit. How often does Medicare cover it? You can get this one-time preventive visit within the first 12 months you have Medicare Part B. What happens during the visit? During the visit, your provider will: Review your medical and social history related to your health. Give you information about preventive services, including certain screenings, shots, or vaccines (like flu, pneumococcal, and other recommended immunizations). Calculate your body mass index (BMI). Give you a simple vision test. Review your potential risk for depression. Offer to talk with you about creating advance directives. Advance directives are legal documents that record your wishes about future medical treatment, in case you’re ever unable to make decisions about your care. Review your potential risk for substance use disorder (like opioid prescription, alcohol, or tobacco use), and refer you for treatment. Give you a written plan (like a checklist) letting you know what screenings, shots, and other preventive services you need. Give you referrals for other care as needed. If you have a current prescription for opioids, your provider will also: Review your potential risk factors for opioid use disorder. Evaluate your pain level and current treatment plan. Give you information on non-opioid treatment options. Refer you to a specialist, if appropriate. What should I bring to the visit? When you go to your “Welcome to Medicare” preventive visit, bring: Your medical records, including immunization records (if you’re seeing a new provider). Call your old provider to get copies of your medical records. Your family health history. Try to learn as much as you can about your family’s health history before your appointment. Any information you can give your provider can help determine if you’re at risk for certain diseases. A list of prescription and over-the-counter drugs that you currently take, how often you take them, and why. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. The Part B deductible doesn’t apply. However, you may have to pay a coinsurance, and the Part B deductible may apply if your provider performs additional tests or services during the same visit that Medicare doesn’t cover under this preventive benefit. If Medicare doesn’t cover the additional tests or services (like a routine physical exam), you may have to pay the full amount. Welcome to Medicare Preventive VisitYearly “Wellness” visitMedicare covers a one-time preventive visit within the first 12 months that you have medicare part b (medical insurance).Have you received either of the following in the past 12 months?"Welcome to Medicare" preventive visit"Wellness" visitWhen did you receive your most recent “Welcome to Medicare” or “Wellness” visit? Info Quick Info The yearly “Wellness” visit isn’t a physical exam. Your doctor or other provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop or update a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include: A review of your medical and family history. A review of your current prescriptions. Routine measurements (like height, weight, and blood pressure A cognitive assessment to look for signs of dementia, including Alzheimer’s disease Personalized health advice. An evaluation of your risk factors for substance use disorder and a referral for treatment, if needed. A screening schedule (like a checklist) for appropriate preventive services Advance care planning An optional “Social Determinants of Health Risk Assessment” to help your provider understand your social needs and their impact on your treatment Am I covered? If you’ve had Medicare Part B for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease and disability, based on your current health and risk factors. How often does Medicare cover it? Once every 12 months. Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit Your costs if you have Original Medicare You pay nothing if your provider accepts assignment. The Part B deductible doesn’t apply. However, you may have to pay a coinsurance, and the Part B deductible may apply if your provider performs additional tests or services during the same visit that Medicare doesn’t cover under this preventive benefit. If Medicare doesn’t cover the additional tests or services (like a routine physical exam), you may have to pay the full amount For more information about Medicare preventive services You can learn more about Medicare’s preventive services by visiting Medicare.gov/coverage/preventive-screening-services. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Yearly Wellness VisitAbdominal Aortic Aneurysm ScreeningHow often is covered? medicare covers this screening once in your lifetime if you get a referral.Do any of the following apply to you?You have a family history of abdominal aortic aneurysmYou’re a man 65-75, and have smoked at least 100 cigarettes in your lifetimeHave you had an abdominal aortic aneurysm screening since you started Medicare?YesNoWhen was your most recent abdominal aortic aneurysm screening done? Info Quick Info Am I covered? Medicare covers an abdominal aortic aneurysm screening ultrasound if you’re at risk. How often does Medicare cover it? Once in your lifetime if you get a referral from your doctor or other provider. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Am I at risk for abdominal aortic aneurysms? You’re considered at risk if any of these are true: You have a family history of abdominal aortic aneurysms? You’re a man 65–75 and have smoked at least 100 cigarettes in your lifetime. Abdominal Aortic Aneurysm ScreeningAlcohol Misuse Screening and CounselingDo you currently use alcohol (beer, wine, or spirits)?YesNoHas a provider ever diagnosed you with alcohol dependency?YesNo Info Quick Info Am I covered? Medicare covers an alcohol misuse screening for adults (including during pregnancy) who use alcohol, but don't meet the medical criteria for alcohol dependency. How often does Medicare cover it? Medicare covers one alcohol misuse screening per year. If your primary care doctor or other provider determines you’re misusing alcohol, you can get up to 4 brief, face‑to‑face counseling sessions per year (if you’re competent and alert during counseling). You must get the counseling in a primary care setting (like a doctor’s office). What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Alcohol Misuse Screening & CounselingBone Mass MeasurementsDo any of the following apply to you?You’re a woman whose provider has determined you’re estrogen-deficient and at risk for osteoporosis, based on your medical history and other findingsYour X-rays show possible osteoporosis, osteopenia, or vertebral fracturesYou’re taking prednisone or steroid-type drugs or plan to begin this treatmentYou’ve been diagnosed with primary hyperparathyroidism.You’re taking an osteoporosis drugHave you had a bone density or bone mass test (DEXA scan) since you started Medicare?YesNoWhen was your most recent bone mass test? Info Quick Info Medicare covers bone mass measurements to see if you’re at risk for broken bones. Your results will help you and your doctor or other provider choose the best way to keep your bones strong. Am I covered? Medicare covers this test if you meet one or more of these conditions: You’re a woman whose provider determines you’re estrogen-deficient and at risk for osteoporosis, based on your medical history and other findings. Your X-rays show possible osteoporosis, osteopenia, or vertebral fractures. You’re taking prednisone or steroid-type drugs or plan to begin this treatment. You’ve been diagnosed with primary hyperparathyroidism. You’re taking an osteoporosis drug./li> How often does Medicare cover it? Once every 24 months (or more often, if medically necessary). What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Bone Mass MeasurementsCardiovascular Behavioral TherapyHow often is it covered? once every 12 months.Have you had a cardiovascular behavioral therapy visit (with diet and lifestyle counseling) since starting Medicare?YesNoWhen was your most recent visit? Info Quick Info Cardiovascular behavioral therapy helps lower your risk for cardiovascular disease. Medicare covers a cardiovascular behavioral therapy visit with your primary care doctor or other primary care practitioner in a primary care setting (like a doctor’s office). During this visit, your primary care practitioner may discuss aspirin use, check your blood pressure, and give you tips on diet and exercise Am I covered? Yes. All people with Medicare can get cardiovascular behavioral therapy. How often does Medicare cover it? Once each year. What are my costs if I have Original Medicare? You pay nothing if your primary care practitioner accepts assignment. Am I at risk for cardiovascular disease? Your risk for cardiovascular disease may increase if: You have high blood pressure. You have unhealthy cholesterol level. You have diabetes. You’re overweight. You use tobacco and/or drink alcohol. You don’t get enough physical activity. You have an unhealthy diet. You have a family history of heart disease. You have a history of preeclampsia (a sudden rise in blood pressure and too much protein in the urine during pregnancy). You’re a woman 55 or older, or a man 45 or older. Cardiovascular Behavioral TherapyCardiovascular Disease ScreeningsHow often is it covered? once every 60 months.Have you had blood tests for cholesterol or heart health (like lipid panel, triglycerides) since you started Medicare?YesNoWhen was your most recent test for cholesterol or heart health? Info Quick Info Medicare covers cardiovascular disease screenings that check your cholesterol, blood fat (lipid), and triglyceride levels. High levels of cholesterol can increase your risk for heart disease and stroke. Am I covered? Yes. All people with Medicare can get cardiovascular disease screenings when a doctor or other provider orders them How often does Medicare cover it? Once every 5 years. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Am I at risk for cardiovascular disease? Refer to “Cardiovascular behavioral therapy” on page 5 for a list of risk factors. Cardiovascular Disease Screenings Not Applicable for Your Selected Gender Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers only for women. You indicated your gender as male, so this screening is not applicable to you. If this was selected in error, you may go back and update your general details before continuing. Otherwise, you may continue to the next question. Cervical and Vaginal Cancer ScreeningsHow often is it covered? medicare covers these screening tests once every 24 months, or once every 12 months if you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal pap test in the past 36 months.Have you had a Pap test or pelvic exam since starting Medicare?YesNoWhen was your most recent Pap test or pelvic exam?Do any of the following apply to you?You have a history of a sexually transmitted disease (including HIV infection)You began having sex before age 16You have had 5 or more sexual partnersYou haven’t had a Pap smear within the last 7 yearsYou only had 1 or 2 normal Pap smears within the last 7 yearsYour mother took DES (Diethylstilbestrol), a hormonal drug, during pregnancyYou are of childbearing age and had an abnormal Pap test in the past 36 monthsWhen was your most recent HPV test with a Pap test? Info Quick Info Medicare covers Pap tests and pelvic exams to check for cervical and vaginal cancers. As part of the pelvic exam, Medicare also covers a clinical breast exam to check for breast cancer Am I covered? If you’re a woman, Medicare covers cervical and vaginal cancer screening. How often does Medicare cover it? Medicare covers these screening tests once every 24 months in most cases. If you’re at high risk for cervical or vaginal cancer, or if you’re of child-bearing age and had an abnormal Pap test in the past 36 months, Medicare covers these screening tests once every 12 months. Medicare also covers Human Papillomavirus (HPV) tests (as part of Pap tests) once every 5 years if you’re 30-65 and don’t have HPV symptoms What are my costs if I have Original Medicare? If your doctor or other provider accepts assignment, you pay nothing for: The lab Pap test. The lab HPV test with the Pap test The Pap test specimen collection The pelvic and breast exams Am I at risk for cervical cancer? Your risk for cervical cancer increases if: You have a history of sexually transmitted disease (including HIV infection). You began having sex before 16. You’ve had 5 or more sexual partners. You haven’t had a Pap smear within the last 7 years. You’ve only had 1 or 2 normal Pap smears within the last 7 years. Your mother took DES (Diethylstilbestrol), a hormonal drug, during pregnancy. Cervical and Vaginal Cancer ScreeningsColorectal Cancer ScreeningsHave you had any colorectal cancer screening tests since starting Medicare?YesNoDo any of the following apply to you?Personal history of colorectal cancerPersonal history of adenomatous polypsFamily history of colorectal cancer or adenomatous polypsPersonal history of inflammatory bowel disease (including Crohn’s disease and ulcerative colitis) Info Quick Info Medicare covers colorectal cancer screening tests to help find precancerous polyps (growths in the colon) or detect cancer early, when treatment works best. Am I covered? If you’re 45 or older, Medicare covers most colorectal cancer screenings (including fecal occult blood tests (screening), flexible sigmoidoscopy screenings, barium enemas (screening), multi-target stool DNA tests (through age 85), and blood-based bio-marker screening tests for colorectal cancer (through age 85)). There’s no minimum age for getting a Medicare-covered screening colonoscopy. How often does Medicare cover it? Screening colonoscopy—Once every 120 months (or once every 24 months if you’re at high risk), or 48 months after a previous flexible sigmoidoscopy. If you initially have a non‑invasive stool‑based screening test (fecal occult blood tests or multi‑target stool DNA test) and get a positive result, Medicare also covers a follow‑up colonoscopy as a screening test. Screening fecal occult blood test—Once every 12 months, if you get a written referral from your doctor, physician assistant, nurse provider, or clinical nurse specialist. Screening flexible sigmoidoscopy—Once every 48 months for most people. If you aren’t at high risk for colorectal cancer, Medicare covers this test 120 months after a previous screening colonoscopy. Screening barium enema—Once every 48 months (or once every 24 months if you’re at high risk) when used instead of a flexible sigmoidoscopy or screening colonoscopy Multi-target stool DNA test—Once every 3 years if you meet all of these conditions: - You show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test. - You’re at average risk for developing colorectal cancer, meaning: You have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (including Crohn’s Disease and ulcerative colitis). You have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. Blood-based biomarker screening tests for colorectal cancer—Once every 3 years if you meet all of these conditions: - You’re between 45–85. - You show no signs or symptoms of colorectal disease including, but not limited to, lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, or fecal immunochemical test. - You’re at average risk for developing colorectal cancer, meaning You have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease (including Crohn’s Disease and ulcerative colitis). You have no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. What are my costs if I have Original Medicare? You pay nothing for the fecal occult blood test, blood-based biomarker test, flexible sigmoidoscopy, screening colonoscopy, or multi-target stool DNA test if your doctor or other provider accepts assignment. Note: If your provider finds and removes a polyp or other tissue during your colonoscopy or flexible sigmoidoscopy, you pay 15% of the Medicare-approved amount for your provider’s services. In a hospital outpatient setting or ambulatory surgical center, you also pay the facility a 15% coinsurance. For barium enemas, you pay 20% of the Medicare-approved amount for your provider’s services. The Part B deductible doesn’t apply. In a hospital outpatient setting, you also pay the hospital a copayment. Am I at risk for colorectal cancer? Risk for colorectal cancer increases with age. It’s important to continue with screenings, even if you were screened before you had Medicare. Your risk for colorectal cancer increases if: You’ve had colorectal cancer before. You have a history of polyps. You have a close relative who had colorectal polyps or colorectal cancer. You have inflammatory bowel disease (like ulcerative colitis or Crohn’s disease). Colorectal Cancer ScreeningsWhich of the following colorectal cancer screening tests have you had since starting Medicare?Screening fecal occult blood testWhen was your most recent fecal occult blood test?Screening colonoscopyWhen was your most recent screening colonoscopy?Screening flexible sigmoidoscopyWhen was your most recent flexible sigmoidoscopy?Screening barium enemaWhen was your most recent barium enema?Multi-target stool DNA test (e.g., Cologuard)When was your most recent stool DNA test?Blood-based biomarker screening testWhen was your most recent blood-based test for colorectal screening? Info Quick Info Welcome to Medicare Preventive VisitCounseling to Prevent Tobacco Use and Tobacco-caused DiseaseDo you currently use any form of tobacco?YesNo Info Quick Info According to the U.S. Surgeon General, people who quit smoking and stop using other forms of tobacco can significantly lower their risk of developing certain diseases. This is true even in older adults who’ve smoked for years. Am I covered? If you use tobacco, Medicare covers smoking and tobacco-use cessation counseling. How often does Medicare cover it? Medicare covers up to 8 counseling sessions in a 12-month period. What are my costs if I have Original Medicare? You pay nothing for the counseling sessions if your doctor or other provider accepts assignment. Ask your provider about Medicare-covered tobacco cessation programs near you, or visit NIH.gov for more information about stopping tobacco use Counseling To Prevent Tobacco UseCOVID-19 VaccinesHave you received a COVID-19 vaccine since starting Medicare?YesNoWhen did you receive your most recent COVID-19 vaccine? Info Quick Info Medicare covers FDA-approved and FDA-authorized COVID-19 vaccines. Am I covered? Yes. All people with Medicare can get COVID-19 vaccines. /p> What are my costs if I have Original Medicare? You pay nothing for the vaccine if your doctor or other provider accepts assignment. COVID-19 VaccinesDepression ScreeningsHave you had a depression screening in a primary care setting since starting Medicare?YesNoWhen was your most recent depression screening? Info Quick Info If you or someone you know is struggling or in crisis, call or text 988, the free and confidential Suicide & Crisis Lifeline. You can call and speak with a trained crisis counselor 24 hours a day, 7 days a week. You can also connect with a counselor through web chat at 988lifeline.org. Call 911 if you’re in an immediate medical crisis Am I covered? Yes. All people with Medicare can get depression screenings. How often does Medicare cover it? Medicare covers one depression screening per year. You must get the screening in a primary care setting (like a doctor’s office) where you can get follow-up treatment and referrals. What are my costs if I have Original Medicare? You pay nothing if your doctor or other provider accepts assignment. Depression ScreeningsDiabetes ScreeningsHas your doctor or other provider determined that you’re at risk for developing diabetes?YesNoHave you had a diabetes screening test since starting Medicare?YesNoWhen was your most recent diabetes screening test? Info Quick Info Diabetes is a medical condition in which your body doesn’t make enough insulin, or has a reduced response to insulin. Diabetes causes your blood sugar to be too high because your body needs insulin to use sugar properly. A high blood sugar level isn’t good for your health. Am I covered? Medicare covers blood glucose (blood sugar) laboratory test screenings (including the Hemoglobin A1C test, and other tests with or without a carbohydrate challenge) if your doctor or other provider determines you’re at risk for developing diabetes. How often does Medicare cover it? You can get up to 2 diabetes screenings per year (within 12 months of your most recent screening). What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Am I at risk for diabetes? You’re considered at risk if you have high blood pressure, a history of abnormal cholesterol and triglyceride levels, obesity, or a history of high blood sugar (glucose). Medicare also covers these tests if 2 or more of these apply to you You’re 65 or older. You’re overweight. You have a family history of diabetes (parents or siblings). You have a history of gestational diabetes (diabetes during pregnancy), or you’ve had a baby weighing more than 9 pounds. Diabetes ScreeningsFlu ShotsHave you had a flu shot since starting Medicare?YesNoWhen was your most recent flu shot? Info Quick Info Am I covered? Yes. All people with Medicare can get the seasonal flu shot How often does Medicare cover it? Once each flu season. What are my costs if I have Original Medicare? You pay nothing if your doctor or other provider accepts assignment. Flu ShotsGlaucoma ScreeningsDo any of the following apply to you?You have diabetesYou have a family history of glaucomaYou’re African American and age 50 or olderYou’re Hispanic and age 65 or olderHave you had a glaucoma test since starting Medicare?YesNoWhen was your most recent glaucoma test? Info Quick Info Glaucoma is an eye disease caused by high pressure in the eye. It can develop gradually without warning and often without symptoms. The best way for people at high risk for glaucoma to protect themselves is to have regular eye exams. Am I covered? Medicare covers these screenings if you’re at high risk for developing glaucoma. How often does Medicare cover it? Once every 12 months. What are my costs if I have Original Medicare? After you meet the Part B deductible, you pay 20% of the Medicare-approved amount. In a hospital outpatient setting, you also pay a copayment Am I at risk for glaucoma? Your risk for glaucoma increases if: You have diabetes. You have a family history of glaucoma. You’re African-American and 50 or older. You’re Hispanic and 65 or older. Glaucoma ScreeningsHepatitis B ShotsDo any of the following apply to you?You have hemophilia and you get factors VII or IXYou have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)You have diabetesYou live with someone who has Hepatitis BYou’re a health care worker and have frequent contact with blood or bodily fluidsYour provider has told you you’re at medium or high risk for Hepatitis BHave you received a Hepatitis B shot since starting Medicare?YesNoWhen did you receive your most recent Hepatitis B shot? Info Quick Info Am I covered? Medicare covers Hepatitis B shots if you’re at medium or high risk for Hepatitis B. What are my costs if I have Original Medicare? You pay nothing for Hepatitis B shots if your doctor or other provider accepts assignment. Am I at risk for Hepatitis B? Your Hepatitis B risk increases if one or more of these conditions applies to you: You have hemophilia and you get factors VII or IX. You have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). You have diabetes. You live with someone who has Hepatitis B. You’re a health care worker and have frequent contact with blood or bodily fluids. Other factors may also increase your risk for Hepatitis B. Check with your provider to find out if you’re at medium or high risk for Hepatitis B. Hepatitis B ShotsHepatitis B Virus (HBV) Infection ScreeningsDo any of the following apply to you?You were born in a country or region with a high prevalence of HBV infectionYou were born in the U.S., not vaccinated as an infant, and your parents were born in regions with a very high prevalence of HBV infectionYou’re HIV-positiveYou’re a man who has sex with menYou’re an injection drug userYou have household contacts or sexual partners with HBV infectionYou are pregnantHave you had a Hepatitis B Virus (HBV) infection screening since starting Medicare?YesNoWhen was your most recent HBV infection screening? Info Quick Info Am I covered? Medicare covers HBV infection screenings if you meet one of these conditions: You’re at high risk for HBV infection. You’re pregnant. Medicare only covers this screening if your Medicare-enrolled doctor or other provider orders it. How often does Medicare cover it? Yearly if you’re at continued high risk and don’t get a Hepatitis B shot. If you’re pregnant: –At the first prenatal visit – At the time of delivery if you have new or continued risk factor – At the first prenatal visit for future pregnancies, even if you previously got the Hepatitis B shot or had negative HBV screening results What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment Am I at risk for HBV? Your risk for HBV increases if: You were born in a country or region with a high prevalence of HBV infection You were born in the U.S., not vaccinated as an infant, and your parents were born in regions with a very high prevalence of HBV infection. You’re HIV-positive. You’re a man who has sex with men. You’re an injection drug user You have household contacts or sexual partners with HBV infection. Hepatitis B Virus Infection ScreeningsHepatitis C Screening TestsDo any of the following apply to you?You’re at high risk because you use or have used illicit injection drugsYou had a blood transfusion before 1992You were born between 1945–1965Have you had a Hepatitis C screening test since starting Medicare?YesNoWhen was your most recent Hepatitis C screening test? Info Quick Info Am I covered? Medicare covers a Hepatitis C screening if your primary care doctor or other provider orders one, and you meet at least one of these conditions. You’re at high risk because you use or have used illicit injection drugs. You had a blood transfusion before 1992. You were born between 1945-1965. How often does Medicare cover it? Once, if you were born between 1945-1965 and aren’t considered high risk. If you’re at high risk, Medicare covers yearly screenings. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Hepatitis C Screening TestsHIV (Human Immunodeficiency Virus) ScreeningsDo any of the following apply to you?You’re between age 15 and 65You are pregnantYou’re a past or present injection drug userYou exchange sex for money or drugs, or have sex partners who doYou have past or present sex partners who are HIV-infected, bisexual, or injection drug usersYou have another sexually transmitted diseaseYou have a history of blood transfusions between 1978 and 1985You have new sexual partnersHave you had an HIV screening test since starting Medicare?YesNoWhen was your most recent HIV screening test? Info Quick Info Am I covered? Medicare covers HIV screenings if you meet one of these conditions: You’re 15–65. You’re younger than 15 or older than 65 and at an increased risk for the virus. How often does Medicare cover it? Once every 12 months, if you meet one of the conditions above. If you’re pregnant, you can get a screening up to 3 times during your pregnancy. What are my costs if I have Original Medicare? You pay nothing if your doctor or other provider accepts assignment. Am I at risk for HIV? Your risk for HIV may increase if: You’re a past or present injection drug user. You exchange sex for money or drugs, or have sex partners who do. You have past or present sex partners who are HIV-infected, bisexual, or injection drug users. You have another sexually transmitted disease. You have a history of blood transfusions between 1978 and 1985. You have new sexual partners. HIV ScreeningsLung Cancer ScreeningsDo any of the following apply to you?You’re 50–77You don’t have signs or symptoms of lung cancer (you’re asymptomatic)You have a tobacco smoking history of at least 20 “pack years” (an average of one pack (20 cigarettes) per day for 20 years)You’re either a current smoker, or you quit smoking within the last 15 yearsHave you had a lung cancer screening with low dose computed tomography (also known as “CT scans”) since starting Medicare?YesNoWhen was your most recent lung cancer screening? Info Quick Info Am I covered? Medicare covers lung cancer screenings with low dose computed tomography (also known as “CT scans”) if you meet all of these conditions: You’re 50–77. You don’t have signs or symptoms of lung cancer (you’re asymptomatic). You have a tobacco smoking history of at least 20 “pack years” (an average of one pack (20 cigarettes) per day for 20 years). You’re either a current smoker, or you quit smoking within the last 15 years. You get an order from your doctor or other provider. How often does Medicare cover it? Once each year. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Am I at risk for lung cancer? Your risk for lung cancer may increase if: You currently smoke tobacco products or smoked them in the past. You’ve been exposed to secondhand smoke. You’ve been exposed to radon, asbestos, or other cancer-causing agents You have a family history of lung cancer Lung Cancer Screenings Not Applicable for Your Selected Gender Medicare covers screening and diagnostic mammograms only for women, typically beginning at age 40, to help detect breast cancer early when treatment is most effective. You indicated your gender as male, so this screening is not applicable to you. If this was selected in error, you may go back and update your general details before continuing. Otherwise, you may continue to the next question. Mammograms (Breast cancer screenings)Are you a woman age 40 or older?YesNoHave you had a screening mammogram since starting Medicare?YesNoWhen was your most recent screening mammogram? Info Quick Info Medicare covers screening mammograms to check for breast cancer before you or a doctor may be able to find it. Every woman is at risk, and this risk increases with age. Breast cancer can usually be treated when found early. Am I covered? If you’re a woman 40 or older, Medicare covers an annual screening mammogram. Medicare also covers diagnostic mammograms and, if you’re a woman between 3539, one baseline mammogram. How often does Medicare cover it? Baseline mammogram: Once in your lifetime. Screening mammograms: Once every 12 months. Diagnostic mammograms: More frequently than once a year, if medically necessary. What are my costs if I have Original Medicare? Screening and baseline mammograms: You pay nothing for the test if your doctor or other provider accepts assignment. Diagnostic mammograms: After you meet the Part B deductible, you pay 20% of the Medicare-approved amount MammogramsMedical Nutrition Therapy ServicesDo any of the following apply to you?You have diabetesYou have kidney diseaseYou’ve had a kidney transplant in the last 36 monthsYou receive dialysis at a dialysis facilityHave you had medical nutrition therapy services since starting Medicare?YesNoWhen did you last receive medical nutrition therapy? Info Quick Info Medicare may cover medical nutrition therapy services and certain related services if a doctor refers you for them. Only a registered dietitian or nutrition professional who meets certain requirements can provide medical nutrition therapy. Services may include: An initial nutrition and lifestyle assessment Individual and/or group nutritional therapy services Help managing the lifestyle factors that affect your diabetes Follow-up visits to check on your progress Am I covered? If you get dialysis in a dialysis facility, Medicare covers medical nutrition therapy as part of your overall dialysis care. Medicare covers medical nutrition therapy services if you have diabetes or kidney disease, or if you’ve had a kidney transplant in the last 36 months. What are my costs if I have Original Medicare? You pay nothing for nutrition therapy services if you qualify for them. Medical Nutrition Therapy ServicesMedicare Diabetes Prevention Program (Male and Female)Do any of the following apply to you?Within the last 12 months you have had a hemoglobin A1c test result between 5.7% and 6.4%, a fasting plasma glucose of 110-125mg/dL, or a 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerant test)You have a body mass index (BMI) of 25 or more (BMI of 23 or more if you’re Asian)You’ve never been diagnosed with type 1 or type 2 diabetes or End-Stage Renal Disease (ESRD)You’ve never participated in the Medicare Diabetes Prevention Program.Medicare Diabetes Prevention ProgramObesity Behavioral TherapyIs your body mass index (BMI) 30 or more?YesNo Info Quick Info Obesity behavioral therapy includes an initial screening for body mass index (BMI), and behavioral therapy sessions that include a dietary assessment and counseling to help you lose weight by focusing on diet and exercise. Medicare covers obesity screenings and behavioral counseling if your primary care doctor or other primary care practitioner gives the counseling in a primary care setting (like a doctor’s office), where they can coordinate your personalized plan with your other care. Am I covered? Medicare covers obesity screenings and behavioral counseling if you have a BMI of 30 or more. What are my costs if I have Original Medicare? You pay nothing if your primary care practitioner accepts assignment. Obesity Behavioral TherapyPneumococcal ShotsHave you received any pneumococcal shots since starting Medicare?YesNo Info Quick Info Medicare covers pneumococcal shots (or vaccines) to help protect against different types of pneumonia. Talk with your doctor or other provider to decide which immunizations are right for you. Am I covered? Yes. All people with Medicare can get pneumococcal shots. What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Pneumococcal Shots Not Applicable for Your Selected Gender Medicare covers digital rectal exams and PSA blood tests only for men age 50 and older, to help detect prostate cancer early. You indicated your gender as female, so this screening is not applicable to you. If this was selected in error, you may go back and update your general details before continuing. Otherwise, you may continue to the next question. Prostate Cancer ScreeningsAre you male and over age 50?YesNo Info Quick Info Your doctor or other provider may find prostate cancer by testing the amount of prostate specific antigen (PSA) in your blood. Your provider can also find prostate cancer during a digital rectal exam. Am I covered? Medicare covers digital rectal exams and PSA blood tests if you’re over 50 (starting the day after your 50th birthday). How often does Medicare cover it? Digital rectal exam—Once every 12 months. PSA blood test—Once every 12 months. What are my costs if I have Original Medicare? Digital rectal exams: After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for a yearly digital rectal exam and for your provider’s services related to the exam. In a hospital outpatient setting, you also pay a separate hospital visit copayment. PSA blood tests: You pay nothing for a yearly PSA blood test. If you get the test from a provider that doesn’t accept assignment, you may have to pay an additional fee for your provider’s services, but not for the test itself. Am I at risk for prostate cancer? Talk to your provider to find out if you’re at risk for prostate cancer. Prostate Cancer ScreeningsHave you had any of the following since starting Medicare?PSA blood testDateDigital rectal examDate Info Quick Info Medicare covers a one-time preventive visit within the first 12 months that you have medicare part b (medical insurance). Sexually Transmitted Infection Screenings & CounselingDo any of the following apply to you?You are pregnantYou have a history of sexually transmitted infectionsYou have had multiple sexual partners in the past yearYou are a man who has sex with menYou use injection drugsYou exchange sex for money or drugsYou have new sexual partnersHave you received a sexually transmitted infection screening or counseling session since starting Medicare?YesNoWhen was your most recent sexually transmitted infection screening or counseling? Info Quick Info Medicare covers sexually transmitted infection screenings for chlamydia, gonorrhea, syphilis, and/or Hepatitis B. Am I covered? Medicare covers these screenings and counseling if you’re pregnant or at increased risk for sexually transmitted infections. Your primary care provider must order the screening or refer you for behavioral counseling. How often does Medicare cover it? Medicare covers sexually transmitted infection screenings once every 12 months or at certain times during pregnancy. Medicare also covers up to 2 behavioral counseling sessions each year. Medicare will only cover counseling sessions with a provider in a primary care setting (like a doctor’s office). Medicare won’t cover counseling as a preventive service in an inpatient setting (like a skilled nursing facility). What are my costs if I have Original Medicare? You pay nothing if your provider accepts assignment. Sexually Transmitted InfectionReview Your Submission Medicare Member Information Name: {name-1} Email: {email-1} Phone: {phone-1} DOB: {date-1} Gender: {radio-1} Gender: {radio-1} Part A Coverage Start Date: {date-3} Part B Coverage Start Date: {date-34} One Time "Welcome To Medicare" Preventive Visit Exam. Have You Had Your Welcome To Medicare Exam? {radio-6} Medicare Exam Date: {date-8} Yearly “Wellness” visit Have you received either of the following in the past 12 months? {checkbox-3} When did you receive your most recent “Welcome to Medicare” or “Wellness” visit? {date-7} Abdominal Aortic Aneurysm Screening Do any of the following apply to you? {checkbox-2} Have you had an abdominal aortic aneurysm screening since you started Medicare? {radio-5} When was your most recent abdominal aortic aneurysm screening done? {date-6} Alcohol Misuse Screening and Counseling Do you currently use alcohol (beer, wine, or spirits)? {radio-7} Has a provider ever diagnosed you with alcohol dependency? {radio-8} Bone Mass Measurements Do any of the following apply to you? {checkbox-4} Have you had a bone density or bone mass test (DEXA scan) since you started Medicare? {radio-10} When was your most recent bone mass test? {date-10} Cardiovascular Behavioral Therapy Have you had a cardiovascular behavioral therapy visit (with diet and lifestyle counseling) since starting Medicare? {radio-11} When was your most recent visit? {date-11} Cardiovascular Disease Screenings Have you had blood tests for cholesterol or heart health (like lipid panel, triglycerides) since you started Medicare? {radio-12} When was your most recent test for cholesterol or heart health? {date-12} Cervical and Vaginal Cancer Screenings Have you had a Pap test or pelvic exam since starting Medicare? {radio-13} When was your most recent Pap test or pelvic exam? {date-13} Do any of the following apply to you? {checkbox-5} Colorectal Cancer Screenings Have you had any colorectal cancer screening tests since starting Medicare? {radio-15} Do any of the following apply to you? {checkbox-7} Counseling to Prevent Tobacco Use and Tobacco-caused Disease Do you currently use any form of tobacco? {radio-16} COVID-19 Vaccines Have you received a COVID-19 vaccine since starting Medicare? {radio-17} When did you receive your most recent COVID-19 vaccine? {date-15} Depression Screenings Have you had a depression screening in a primary care setting since starting Medicare? {radio-18} When was your most recent depression screening? {date-16} Diabetes Screenings Has your doctor or other provider determined that you’re at risk for developing diabetes? {radio-19} Have you had a diabetes screening test since starting Medicare? {radio-20} When was your most recent diabetes screening test? {date-17} Flu Shots Have you had a flu shot since starting Medicare? {radio-21} When was your most recent flu shot? {date-18} Glaucoma Screenings Do any of the following apply to you? {checkbox-8} Have you had a glaucoma test since starting Medicare? {radio-22} When was your most recent glaucoma test? {date-19} Hepatitis B Shots Do any of the following apply to you? {checkbox-9} Have you received a Hepatitis B shot since starting Medicare? {radio-23} When did you receive your most recent Hepatitis B shot? {date-20} Hepatitis B Virus (HBV) Infection Screenings Do any of the following apply to you? {checkbox-10} Have you had a Hepatitis B Virus (HBV) infection screening since starting Medicare? {radio-24} When was your most recent HBV infection screening? {date-21} Hepatitis C Screening Tests Do any of the following apply to you? {checkbox-11} Have you had a Hepatitis C screening test since starting Medicare? {radio-25} When was your most recent Hepatitis C screening test? {date-22} HIV (Human Immunodeficiency Virus) Screenings Do any of the following apply to you? {checkbox-12} Have you had an HIV screening test since starting Medicare? {radio-26} When was your most recent HIV screening test? {date-23} Lung Cancer Screenings Do any of the following apply to you? {checkbox-13} Have you had a lung cancer screening with low dose computed tomography (also known as “CT scans”) since starting Medicare? {radio-27} When was your most recent lung cancer screening? {date-24} Mammograms (Breast cancer screenings) Are you a woman age 40 or older? {radio-28} Have you had a screening mammogram since starting Medicare? {radio-29} When was your most recent screening mammogram? {date-25} Medical Nutrition Therapy Services Do any of the following apply to you? {checkbox-14} Have you had medical nutrition therapy services since starting Medicare? {radio-30} When did you last receive medical nutrition therapy? {date-26} Medicare Diabetes Prevention Program (Male and Female) Do any of the following apply to you? {checkbox-26} Obesity Behavioral Therapy Is your body mass index (BMI) 30 or more? {radio-31} Pneumococcal Shots Have you received any pneumococcal shots since starting Medicare? {radio-32} Prostate Cancer Screenings Are you male and over age 50? {radio-33} Sexually Transmitted Infection Screenings & Counseling Do any of the following apply to you? {checkbox-16} Have you received a sexually transmitted infection screening or counseling session since starting Medicare? {radio-34} When was your most recent sexually transmitted infection screening or counseling? {date-27} I understand that this tool is for educational purposes only and does not replace medical advice. 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