Knowledge Base Article

In 1735, Benjamin Franklin noted that “an ounce of prevention is worth a pound of cure.” Although Franklin was actually addressing fire safety, this axiom is also true in reference to health. The Centers for Disease Control (CDC) in an article about the National Prevention Strategy states that “Increasing the focus on prevention in our communities will help improve America's health, quality of life and prosperity.” And in the long run, prevention reduces health care costs for patients, providers, and insurers. So it is not surprising that CMS is continuing to expand Medicare preventive and screening services.

On April 13, 2015, CMS released a Final Decision Memorandum expanding the coverage of HIV Screening for Medicare beneficiaries. Medicare has offered coverage of HIV screening since December 2008, but only covered the screening for individuals with certain high-risk factors or during pregnancy. This latest decision memo expands coverage to an annual screening for all Medicare beneficiaries between the ages of 15-65.

The complete list of covered conditions for HIV screening includes:

• A maximum of one, annual voluntary screening for all adolescents and adults between the age of 15 and 65, without regard to perceived risk;
• A maximum of one, annual voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection. Increased risk for HIV infection is defined as follows:
• Men who have sex with men
• Men and women having unprotected vaginal or anal intercourse
• Past or present injection drug users
• Men and women who exchange sex for money or drugs, or have sex partners who do
• Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users
• Persons who have acquired or request testing for other sexually transmitted infectious diseases
• Persons with a history of blood transfusions between 1978 and 1985
• Persons who request an HIV test despite reporting no individual risk factors
• Persons with new sexual partners
• Persons who based on individualized physician interview and examination are deemed to be at increased risk for HIV infection.
• A maximum of three, voluntary HIV screenings of pregnant Medicare beneficiaries: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and (3) at labor, if ordered by the woman’s clinician.

In addition to the list of covered conditions, testing for HIV screening must also meet the following requirements.

• An FDA approved laboratory test or point of care test
• Testing in accordance with FDA approved labeling and compliant with CLIA regulations
• Ordered by the patient’s physician or practitioner within the context of a healthcare setting
• Performed by an eligible Medicare provider or supplier for these services

Remember that Medicare Administrative Contractors’ (MACs) claims processing systems may not yet be ready to accept claims under the new coverage conditions. Within a few months, Medicare will publish a transmittal updating the National Coverage Determination Manual and claims processing instructions if needed, with an effective date by which MACs should be prepared to accept claims under the new guidelines.

In related news, Medicare released a proposed decision memorandum on April 16, 2015 that proposes the coverage of Human Papillomavirus (HPV) testing for screening for cervical cancer. The memo recommends HPV testing once every five years for asymptomatic beneficiaries aged 30 to 65 in conjunction with the Pap smear test. CMS is currently accepting comments on this proposal and will respond to public comments in a final decision memorandum.

Moving healthcare towards a focus on prevention will hopefully improve the physical and financial health of America. Unfortunately today, the US spends more per capita on healthcare than many other nations, but does not have better health outcomes to show for it. Maybe this “ounce of prevention” will bring forth that “pound of cure.”