Georgia Medicare Preventive Services Benefit

::: hero

By Brevy Care Team · Last verified May 13, 2026

Medicare covers a broad and growing portfolio of preventive services designed to detect disease early, prevent complications, and support healthy aging. Section 1861(ddd) of the Social Security Act is the umbrella authority under which the Secretary of Health and Human Services adds preventive services based on United States Preventive Services Task Force Grade A or B recommendations. Section 1861(s)(2)(W) covers the Welcome to Medicare Initial Preventive Physical Examination available within the first 12 months of Part B. Section 1861(hhh) covers the Annual Wellness Visit available annually thereafter. Sections 1834(c), 1834(d), 1861(nn), 1861(jj), 1861(yy), 1861(uu), 1861(ggg), and others establish discrete screening benefits for breast cancer, colorectal cancer, cervical cancer, osteoporosis, abdominal aortic aneurysm, diabetes, and cardiovascular disease. The Affordable Care Act of 2010 Sections 4103 and 4104 created the Annual Wellness Visit and eliminated Part B cost-sharing for the IPPE, AWV, and USPSTF Grade A or B preventive services. The Inflation Reduction Act of 2022 Section 11401 eliminated Part D cost-sharing for adult vaccines effective January 1, 2023. This guide explains the federal statutory and regulatory framework, the distinction between the IPPE, the AWV, and an annual physical, the screening services covered with zero cost-sharing, frequency and eligibility rules, and how Georgia beneficiaries access preventive care through primary care, FQHCs, and other settings. :::

::: callout Key takeaways for Georgia Medicare preventive services:

1. Section 1861(ddd) of the Social Security Act is the umbrella authority under which the Secretary of HHS adds preventive services based on United States Preventive Services Task Force Grade A or B recommendations. This is how lung cancer screening, hepatitis C screening, depression screening, and other modern preventive services entered Medicare.

2. Section 1861(s)(2)(W) establishes the Initial Preventive Physical Examination (IPPE), commonly called "Welcome to Medicare." The IPPE is a once-in-a-lifetime benefit available during the first 12 months of Part B enrollment. HCPCS G0402. Zero cost-sharing under ACA Section 4104 effective January 1, 2011.

3. Section 1861(hhh) establishes the Annual Wellness Visit (AWV), added by ACA Section 4103. The AWV is available annually after 12 months of Part B enrollment. HCPCS G0438 for the initial AWV and G0439 for subsequent AWVs. Zero cost-sharing from inception.

4. ACA Section 4104 eliminated Part B deductible and coinsurance for the IPPE, AWV, and USPSTF Grade A or B preventive services effective January 1, 2011. Provider must accept assignment for the no-cost-sharing benefit to apply.

5. Screening mammography under Section 1834(c) is covered annually for women age 40 and older with zero cost-sharing. Screening pap/pelvic under Section 1861(nn) is covered every 24 months (or 12 months high-risk) with zero cost-sharing.

6. Colorectal cancer screening under Section 1834(d) covers FOBT/FIT annually, Cologuard every 3 years, colonoscopy every 10 years (24 months high-risk), flexible sigmoidoscopy every 4 years, and CT colonography every 5 years. The Bipartisan Budget Act 2018 Section 50403 and CAA 2021 Section 122 phase down coinsurance when a screening colonoscopy is converted to diagnostic; full zero cost-sharing arrives in 2030.

7. Bone mass measurement under Section 1861(jj) is covered every 24 months (12 months high-risk) with zero cost-sharing. AAA screening under Section 1861(yy) is once-in-a-lifetime for men 65-75 ever-smoked or with family history.

8. The Inflation Reduction Act of 2022 Section 11401 eliminated Part D cost-sharing for adult vaccines effective January 1, 2023. Shingles (Shingrix), Tdap, hepatitis A, and other ACIP-recommended adult vaccines are now zero cost-sharing under Part D, joining Part B influenza, pneumococcal, hepatitis B (risk-based), and COVID-19 vaccines. :::

Federal Statutory and Regulatory Authority for Medicare Preventive Services

Medicare's preventive services portfolio has expanded dramatically since the program began in 1965. What was initially limited to a small set of inpatient and physician services now includes more than 25 distinct preventive benefits authorized under various sections of the Social Security Act and implementing regulations. Georgia beneficiaries and the families helping them coordinate care should understand the statutory backbone because billing disputes and coverage questions almost always resolve to a specific provision.

Section 1861(ddd) of the Social Security Act: The USPSTF Umbrella Authority

Section 1861(ddd) of the Social Security Act, codified at 42 U.S.C. 1395x(ddd), is the umbrella authority by which the Secretary of Health and Human Services may add additional preventive services to Medicare coverage. Section 1861(ddd) was added by Section 101 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA, Public Law 110-275).

Under Section 1861(ddd), the Secretary may determine that a service is covered as a Medicare preventive service if:

1. The service is reasonable and necessary for the prevention or early detection of an illness or disability
2. The service is recommended with a grade of A or B by the United States Preventive Services Task Force
3. The service is appropriate for individuals entitled to benefits under Part A or enrolled under Part B

The USPSTF-Medicare link under Section 1861(ddd) has enabled the program to expand its preventive portfolio without requiring new statutory authorization for each service. Services added under Section 1861(ddd) authority since 2009 include:

• Lung cancer screening with low-dose computed tomography
• Hepatitis C virus screening (baby boomer cohort and risk-based)
• HIV screening
• Intensive behavioral therapy for obesity
• Intensive behavioral therapy for cardiovascular disease
• Sexually transmitted infection screening and counseling
• Alcohol misuse screening and behavioral counseling
• Tobacco use cessation counseling
• Depression screening in primary care
• Counseling for prevention of falls
• Annual screening for hepatitis B virus infection

Section 1861(s)(2)(W) of the Social Security Act: The Initial Preventive Physical Examination

Section 1861(s)(2)(W) establishes the Initial Preventive Physical Examination (IPPE), commonly known as "Welcome to Medicare." The IPPE was added by Section 611 of the Medicare Modernization Act of 2003 (MMA, Public Law 108-173) effective January 1, 2005.

The IPPE is a once-in-a-lifetime benefit available during the first 12 months of Part B enrollment. The visit covers:

• Review of medical and social history
• Review of family history
• Review of current opioid prescriptions and any opioid use disorder
• Screening for potential substance use disorders
• Vital signs measurement (height, weight, BMI, blood pressure)
• Vision screening
• Depression screening (including review of risk factors)
• Functional ability and safety screening
• End-of-life planning discussion
• Education, counseling, and referrals
• Written plan obtaining screening and other preventive services
• Optional EKG screening (HCPCS G0403, G0404, G0405)

The IPPE was originally subject to Part B deductible and 20% coinsurance. Effective January 1, 2011, ACA Section 4104 eliminated cost-sharing for the IPPE. HCPCS G0402 is used to bill the IPPE.

Section 1861(hhh) of the Social Security Act: The Annual Wellness Visit

Section 1861(hhh) was added by Section 4103 of the Patient Protection and Affordable Care Act (Public Law 111-148) effective January 1, 2011. The Annual Wellness Visit (AWV) is the successor benefit to the IPPE for ongoing Medicare beneficiaries.

The AWV is available annually after 12 months of Part B enrollment and includes:

• Health risk assessment (HRA), typically completed before the visit
• Establishment of medical/family history
• Current providers and prescription medications list
• Vital signs measurement
• Cognitive impairment detection
• Functional ability and level of safety
• Depression screening
• Fall risk assessment
• Personalized prevention plan with personalized health advice
• Schedule of recommended screening tests and services
• Advance care planning may be furnished as part of the AWV (HCPCS G0444)

HCPCS G0438 is used to bill the initial AWV (the first AWV after the IPPE period). HCPCS G0439 is used to bill subsequent AWVs. The AWV has zero cost-sharing under ACA Section 4104 from inception.

IPPE vs. AWV vs. Annual Physical Examination

A common source of beneficiary confusion is the difference between the IPPE, the AWV, and a traditional annual physical exam. The distinctions matter for both clinical content and billing.

The IPPE is a once-in-a-lifetime visit within the first 12 months of Part B enrollment. It is a comprehensive preventive visit but not a traditional physical exam.

The AWV is an annual structured health risk assessment and personalized prevention plan visit available after 12 months of Part B. It is NOT a comprehensive physical exam.

A traditional annual physical exam is not a Medicare-covered benefit. Medicare does not pay for a routine physical exam outside the IPPE/AWV framework.

Combined visits are common in practice. Many physicians furnish an AWV combined with an evaluation and management (E/M) visit when chronic conditions or new complaints require attention during the same appointment. In that case the AWV portion is billed with zero cost-sharing; the E/M portion is billed separately with modifier 25 and is subject to Part B cost-sharing. Georgia beneficiaries should ask the practice billing office to clarify how a combined visit will be billed before the appointment.

Section 1834(c) of the Social Security Act: Screening Mammography

Section 1834(c) covers screening mammography. The benefit was originally established by Section 4163 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) and has been refined repeatedly.

Coverage:

• Annual screening mammography for women age 40 and older
• Baseline mammography for women age 35 through 39
• HCPCS 77067 (screening mammography, bilateral)
• HCPCS 77063 (screening digital tomosynthesis, an additional code billable with 77067)
• Zero cost-sharing under ACA Section 4104

Note that diagnostic mammography (HCPCS 77066) performed in response to a clinical finding or following an abnormal screening is a different service and is subject to Part B cost-sharing.

Section 1834(d) of the Social Security Act: Colorectal Cancer Screening

Section 1834(d) covers colorectal cancer screening. The benefit was established by Section 4104 of the Balanced Budget Act of 1997 and has been expanded multiple times.

Tests covered:

• Fecal occult blood test (FOBT) annually
• Fecal immunochemical test (FIT) annually
• Multi-target stool DNA test (Cologuard) every 3 years
• Flexible sigmoidoscopy every 4 years (or 10 years following negative colonoscopy)
• Colonoscopy every 10 years for average-risk beneficiaries; every 24 months for high-risk
• Barium enema every 4 years (alternative to flex sig or colonoscopy)
• CT colonography every 5 years

Cost-sharing history for screening colonoscopy. Originally, when a screening colonoscopy resulted in polyp removal, the visit was converted to diagnostic and the full 20% (later 25%) coinsurance applied. The Bipartisan Budget Act of 2018 Section 50403 and the Consolidated Appropriations Act of 2021 Section 122 implemented a phased reduction in coinsurance:

• 2022: 20% coinsurance
• 2023 through 2026: 15% coinsurance
• 2027 through 2029: 10% coinsurance
• 2030 onward: 0% coinsurance

This phase-down was a major win for beneficiary advocates and addressed the long-standing barrier of unexpected coinsurance bills when polyps were detected during a "free" screening.

Section 1861(nn) of the Social Security Act: Screening Pap/Pelvic

Section 1861(nn) covers screening pap smear and pelvic exam. The benefit was established by Section 4101 of OBRA 1990.

Coverage:

• Every 24 months for women at standard risk
• Every 12 months for women at high risk (history of cervical or vaginal cancer, recent abnormal pap, certain other risk factors)
• HCPCS G0101 (screening pelvic exam) and Q0091 (screening pap smear specimen collection)
• Zero cost-sharing under ACA Section 4104

Section 1861(jj) of the Social Security Act: Bone Mass Measurement

Section 1861(jj) covers bone mass measurement. The benefit was added by Section 4106 of the Balanced Budget Act of 1997.

Coverage:

• Every 24 months for individuals at risk for osteoporosis
• More frequent if medically necessary
• Tests include DEXA (HCPCS 77080), quantitative ultrasound, quantitative CT, and single-energy X-ray
• Zero cost-sharing under ACA Section 4104

Qualifying risk groups:

• Estrogen-deficient women at clinical risk for osteoporosis
• Patients with X-ray showing osteopenia or osteoporosis
• Patients receiving (or expected to receive) long-term glucocorticoid therapy (more than 3 months)
• Patients with primary hyperparathyroidism
• Patients being monitored for response to osteoporosis treatment

Section 1861(yy) of the Social Security Act: Abdominal Aortic Aneurysm Screening

Section 1861(yy) covers screening for abdominal aortic aneurysm. The benefit was added by Section 5112 of the Deficit Reduction Act of 2005.

Coverage:

• Once-in-a-lifetime benefit
• Men age 65 to 75 who have ever smoked
• Men or women age 65 to 75 with family history of AAA
• Referral required via the IPPE/AWV
• HCPCS G0389 (ultrasound screening for AAA)
• Zero cost-sharing under ACA Section 4104

Section 1861(uu) of the Social Security Act: Diabetes Screening Blood Test

Section 1861(uu) covers diabetes screening blood tests. Added by MMA 2003.

Coverage:

• Annual diabetes screening for beneficiaries with risk factors
• Twice annual for high-risk beneficiaries
• Fasting plasma glucose, post-glucose challenge test, or hemoglobin A1c
• Zero cost-sharing under ACA Section 4104

Section 1861(ggg) of the Social Security Act: Cardiovascular Disease Screening

Section 1861(ggg) covers cardiovascular disease screening blood tests. Added by MMA 2003.

Coverage:

• Every 5 years
• Total cholesterol, HDL cholesterol, triglycerides
• Zero cost-sharing under ACA Section 4104

Section 1861(qq) of the Social Security Act: Diabetes Self-Management Training

Section 1861(qq) covers diabetes outpatient self-management training (DSMT). Added by Section 4105 of the Balanced Budget Act of 1997.

Coverage:

• Up to 10 hours of initial DSMT in the first year following diagnosis
• 2 hours of follow-up DSMT annually thereafter
• Furnished by an ADA-recognized or AADE-accredited DSMT program
• Subject to Part B deductible and 20% coinsurance (not on the ACA zero-cost-sharing list because DSMT is a separate Section 1861 benefit not a USPSTF Grade A or B service)

IRA 2022 Adult Vaccine Cost-Sharing Elimination

Section 11401 of the Inflation Reduction Act of 2022 (Public Law 117-169) eliminated Part D cost-sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). The provision was effective January 1, 2023.

Adult vaccines now covered without cost-sharing under Part D:

• Shingles (Shingrix)
• Tdap (tetanus, diphtheria, pertussis)
• Hepatitis A
• Other ACIP-recommended adult vaccines not already covered under Part B

Vaccines covered without cost-sharing under Part B (separate from IRA 2022):

• Influenza vaccine (annual)
• Pneumococcal vaccine (PCV20, or sequential PCV15 + PPSV23, per ACIP)
• Hepatitis B vaccine (for high-risk and intermediate-risk beneficiaries)
• COVID-19 vaccine (added by CARES Act 2020 Section 3713; permanent post-PHE)

Section 1833(a)(1)(F) of the Social Security Act: Zero Cost-Sharing Mechanism

Section 1833(a)(1)(F) is the statutory provision that implements zero cost-sharing for preventive services. Under this provision:

• No Part B deductible applies to the IPPE, AWV, or USPSTF Grade A/B preventive services
• No coinsurance applies to these services
• The provider must accept assignment for the no-cost-sharing benefit
• The service must be billed correctly with the appropriate HCPCS code
• The service must be furnished within the applicable frequency and eligibility rules

Federal Regulatory Framework

The Code of Federal Regulations Title 42 implements the statutory preventive benefits. Key regulations include:

42 CFR 410.15 establishes the AWV coverage conditions including the beneficiary's Part B enrollment duration, the required elements, the annual frequency rule, and the qualified furnishing provider.

42 CFR 410.16 establishes the IPPE coverage conditions including the first-12-month window, the once-in-a-lifetime rule, and the required visit elements.

42 CFR 410.17 establishes cardiovascular screening blood test conditions including the 5-year frequency and the three required tests.

42 CFR 410.18 establishes diabetes screening conditions including risk-based frequency.

42 CFR 410.19 establishes AAA ultrasound screening conditions including the eligible cohorts and the IPPE/AWV referral requirement.

Together, these regulations operationalize the Section 1861 statutory benefits and provide the detailed billing rules Medicare Administrative Contractors apply.

Frequency and Eligibility Rules

Beneficiaries can lose coverage if they exceed frequency limits or fail to meet eligibility criteria.

IPPE. Once-in-a-lifetime, within the first 12 months of Part B enrollment.

AWV. Annual after 12 months of Part B enrollment. Cannot be furnished in the same 12-month period as another AWV.

Screening mammography. Annual for women age 40+. Baseline allowed for women age 35-39. Counts from the date of the most recent prior screening, not from the date of last service.

Screening pap/pelvic. Every 24 months for standard risk; every 12 months for high-risk.

Bone mass measurement. Every 24 months for risk-based eligibility; more frequent if medically necessary (for example, glucocorticoid therapy monitoring).

Colorectal cancer screening. Varies by test (FOBT/FIT annual; Cologuard every 3 years; colonoscopy every 10 years average-risk or 24 months high-risk).

Cardiovascular disease screening. Every 5 years.

Diabetes screening. Annual for risk factors; twice annual for high-risk.

AAA screening. Once-in-a-lifetime for eligible cohorts.

Glaucoma screening. Annual for high-risk groups.

Prostate cancer screening (PSA + DRE). Annual for men 50+.

Lung cancer LDCT screening. Annual for eligible smokers age 50-77 with 20+ pack-year history.

How the Zero Cost-Sharing Benefit Works in Practice

For the IPPE, AWV, and USPSTF Grade A/B preventive services:

1. The provider must accept assignment for the service.
2. The beneficiary should choose a Medicare-participating provider whenever possible.
3. The service must be billed with the appropriate HCPCS code (G0438/G0439 for AWV, G0402 for IPPE, etc.).
4. The service must meet frequency and eligibility requirements.
5. Documentation must support medical necessity and appropriate coding.

When all conditions are met, the beneficiary pays nothing for the preventive service: no Part B deductible and no coinsurance.

Important caveats. If a preventive visit is converted to diagnostic (for example, a polyp removed during screening colonoscopy, or a diagnostic mammogram following an abnormal screening), the converted service is subject to standard Part B cost-sharing or the phased coinsurance reduction (for screening colonoscopy converted to diagnostic).

Palmetto GBA Jurisdiction J: Georgia's Medicare Administrative Contractor

Palmetto GBA serves as the Medicare Administrative Contractor for Jurisdiction J Part B, covering Georgia, Alabama, and Tennessee. Palmetto:

• Processes Part B claims for preventive services
• Issues local coverage guidance
• Conducts medical reviews for selected services
• Provides provider education

Phone: 1-877-567-9230. Website: palmettogba.com.

When a Georgia beneficiary believes a preventive service was incorrectly billed (for example, deductible or coinsurance applied to a service that should have been zero cost-sharing), the first step is to contact the provider's billing office. If unresolved, the beneficiary can file a Medicare appeal with Palmetto GBA.

Georgia Preventive Care Landscape

Georgia beneficiaries have access to preventive services through diverse channels.

Primary Care Providers

Most preventive services are delivered in primary care. Major Georgia hospital systems operating primary care networks include:

• Emory Healthcare Primary Care
• Piedmont Primary Care
• Wellstar Medical Group Primary Care
• Northeast Georgia Physicians Group
• Memorial Health Primary Care
• Augusta University Medical Associates
• Atrium Health Navicent Primary Care
• Phoebe Physician Group
• Grady Primary Care Centers

In addition, Georgia has thousands of independent primary care practices across the state.

Federally Qualified Health Centers (FQHCs)

Georgia has more than 30 FQHC organizations operating over 200 sites statewide, providing comprehensive primary care including preventive services on a sliding-fee scale and accepting Medicare. FQHCs are particularly important in rural Georgia and underserved urban neighborhoods.

Major Georgia FQHC organizations include Albany Area Primary Health Care, Christ Community Health Services, Curtis V. Cooper Primary Health Care (Savannah), Diversity Health Center, Good Samaritan Health Center, Mercy Care Atlanta, Morehouse Healthcare, Neighborhood Health Center, Quality of Life Health Services, and many others.

To find a Georgia FQHC, beneficiaries can call HRSA at 1-877-464-4772 or use the HRSA Find a Health Center tool at findahealthcenter.hrsa.gov.

Georgia Department of Public Health County Health Departments

GA DPH operates 18 health districts encompassing all 159 Georgia counties. County health departments provide select preventive services including immunizations, certain screenings, and women's health services (often through the Breast and Cervical Cancer Early Detection Program). The GA DPH main line is 404-657-2700.

Specialty Preventive Care

Beyond primary care, Georgia beneficiaries access specialty preventive services at:

• Mammography centers (Emory Breast Imaging, Piedmont, Wellstar, multiple imaging centers statewide)
• Colonoscopy centers (hospital outpatient endoscopy, independent ambulatory surgery centers)
• LDCT lung cancer screening centers (major hospital radiology departments)
• Bone density (DEXA) imaging centers
• Vaccine pharmacy services (CVS, Walgreens, Publix, Kroger, Walmart pharmacy)

Worked Examples for Georgia Beneficiaries

The following examples illustrate how the federal framework applies to Georgia beneficiaries in common preventive care scenarios. Names and details are illustrative.

Example 1: Margaret, Age 78, Atlanta: Annual Wellness Visit at Piedmont Primary Care

Margaret has been enrolled in Medicare Part B for 13 years. She schedules her Annual Wellness Visit with her Piedmont primary care physician. The visit covers:

• Health risk assessment questionnaire (completed at home before the visit)
• Medical and family history update
• Current medications and provider list
• Vital signs measurement
• Cognitive impairment screening (Mini-Cog)
• Functional ability assessment
• Depression screening (PHQ-9)
• Fall risk assessment
• Personalized prevention plan and 5-year screening schedule

Margaret's PCP also addresses her hypertension and diabetes management during the same visit (separate E/M with modifier 25 to indicate a separate, identifiable service). The AWV portion is billed with HCPCS G0439 (subsequent AWV) and has no cost-sharing. The E/M portion is billed separately and is subject to Part B cost-sharing. Margaret's Medigap Plan G covers the E/M coinsurance.

Outcome: Margaret receives her AWV at no cost; her chronic-care E/M visit cost-sharing is covered by Medigap.

Example 2: Robert, Age 82, Savannah: Screening Colonoscopy at Memorial Health

Robert is due for his 10-year screening colonoscopy. His PCP refers him to a Memorial Health gastroenterologist. The colonoscopy is performed at Memorial Health's outpatient endoscopy suite. A small polyp is detected and removed during the procedure (converted from screening to diagnostic).

Pre-2018, the polyp removal would have triggered full 25% coinsurance for the entire visit. Under the Bipartisan Budget Act of 2018 Section 50403 and CAA 2021 Section 122 phase-down:

• 2022: 20% coinsurance
• 2023 through 2026: 15% coinsurance
• 2027 through 2029: 10% coinsurance
• 2030 onward: 0% coinsurance

Robert pays 15% coinsurance for the polyp-removal portion in 2026. His Medigap Plan N covers the coinsurance. The pre-removal colonoscopy facility component remains no-cost-sharing as a screening service.

Outcome: Robert's screening colonoscopy is largely covered with no out-of-pocket cost; the polyp-removal coinsurance is covered by Medigap.

Example 3: Linda, Age 75, Macon: DEXA Bone Density at Atrium Navicent

Linda is post-menopausal and has not had a bone density scan in 5 years. Her PCP at Atrium Health Navicent orders a DEXA scan to assess osteoporosis risk. The scan is performed at Atrium Navicent's imaging center.

HCPCS 77080 (axial DEXA) is billed under Section 1861(jj) every 24 months for risk-based eligibility. Linda has no cost-sharing under ACA Section 4104.

The DEXA results show osteopenia (T-score -1.5). Linda's PCP discusses calcium, vitamin D, weight-bearing exercise, fall prevention strategies, and shared decision-making about pharmacologic options. The PCP also schedules her next DEXA in 24 months.

Outcome: Linda's DEXA bone density scan is covered with zero cost-sharing.

Example 4: Charles, Age 80, Augusta: Lung Cancer Screening LDCT at AU Medical

Charles is a former smoker with a 40 pack-year history (he quit 5 years ago). He meets lung cancer screening eligibility criteria (age 50-77, 20+ pack-year history, current smoker or quit within 15 years). His PCP at AU Medical Center conducts the required shared decision-making visit (HCPCS G0296) and orders a screening low-dose computed tomography (LDCT) of the chest.

The LDCT is performed at AU Medical's radiology department. HCPCS G0297 (LDCT lung cancer screening) is billed under Section 1861(ddd) authority (added by CMS NCD 210.14 effective February 5, 2015). Charles has no cost-sharing for the LDCT or the shared decision-making visit.

The LDCT reveals a small pulmonary nodule (Lung-RADS 3) that requires follow-up CT in 6 months. The follow-up CT in 6 months is diagnostic (not screening) and is subject to standard Part B cost-sharing.

Outcome: Charles's screening LDCT and shared decision-making visit are covered with zero cost-sharing. Diagnostic follow-up imaging will be subject to standard Part B rules.

Example 5: Patricia, Age 73, Columbus: Annual Mammogram and Biennial Pap

Patricia visits her gynecologist at Piedmont Columbus Regional for her annual screening mammography and biennial screening pap. Both services are covered under their respective statutory provisions with zero cost-sharing.

The screening mammogram is billed using HCPCS 77067 (screening mammography, bilateral) under Section 1834(c). The radiology center adds HCPCS 77063 for screening digital tomosynthesis.

The pap is billed using HCPCS Q0091 (specimen collection) and G0101 (screening pelvic exam) under Section 1861(nn).

Both services are zero-cost-sharing under ACA Section 4104. The mammogram shows a small mass (BI-RADS 4) requiring diagnostic follow-up. The diagnostic mammogram (HCPCS 77066) ordered next week is not covered under the screening benefit and is subject to standard Part B cost-sharing.

Outcome: Patricia's screening mammogram and pap are covered with zero cost-sharing. Diagnostic follow-up mammogram is subject to standard cost-sharing.

Example 6: Henry, Age 85, Athens: Cardiovascular Screening and AAA Decision

Henry is an 85-year-old non-smoker. At his AWV at St. Mary's Health Care System in Athens, his PCP reviews his preventive care schedule. Henry has not had a cardiovascular screening blood test in 5+ years and qualifies for one.

His PCP orders:

• Cardiovascular screening: total cholesterol, HDL, triglycerides under Section 1861(ggg) (every 5 years; no cost-sharing)
• Diabetes screening: hemoglobin A1c under Section 1861(uu) (annual for high-risk; Henry has prediabetes so qualifies; no cost-sharing)

AAA screening is not ordered because Henry has never smoked and has no family history of AAA. (Even if eligible, AAA screening is a once-in-a-lifetime benefit for the eligible cohorts.)

The PCP also reviews Henry's vaccination status. He is due for an influenza vaccine (annual) and a shingles vaccine (Shingrix) under Part D with zero cost-sharing post-IRA 2022. Both vaccines are administered at a CVS pharmacy adjacent to the clinic.

Outcome: Henry receives his AWV, cardiovascular screening, diabetes screening, and both vaccines with zero cost-sharing.

Common Mistakes to Avoid

1. Confusing the IPPE with the AWV. The IPPE is a once-in-a-lifetime "Welcome to Medicare" exam within the first 12 months of Part B; the AWV is an annual visit available after 12 months.

2. Confusing the AWV with an annual physical exam. The AWV is a structured health risk assessment and prevention planning visit. It is NOT a comprehensive physical exam. Medicare does not cover routine annual physical exams.

3. Forgetting that some services require shared decision-making before screening. Lung cancer screening with LDCT requires a documented shared decision-making visit (HCPCS G0296) before the first screening exam.

4. Believing all preventive services are zero cost-sharing. ACA Section 4104 zero cost-sharing applies to the IPPE, AWV, and USPSTF Grade A/B services. DSMT, MNT, and certain other Section 1861 benefits remain subject to Part B deductible and 20% coinsurance.

5. Failing to understand the screening-to-diagnostic conversion. When a screening colonoscopy results in polyp removal, the visit converts to diagnostic, triggering coinsurance (phased down through 2030 to 0%).

6. Missing frequency limits. Beneficiaries can lose coverage if they exceed frequency limits (for example, scheduling a screening mammogram 11 months after the prior one, before the annual frequency rule allows the next one).

7. Failing to recognize Section 1861(ddd) services. Many newer preventive services (lung cancer LDCT screening, hepatitis C screening, depression screening) are authorized under Section 1861(ddd) rather than discrete statutory provisions. Coverage and billing rules apply the same way.

8. Not using a Medicare-participating provider. The zero-cost-sharing benefit requires the provider to accept assignment. Non-participating providers may charge the limiting charge (up to 115% of the Medicare-approved amount).

9. Confusing Medicare Part B preventive services with Part D vaccines. Influenza, pneumococcal, hepatitis B (risk-based), and COVID-19 vaccines are Part B benefits. Other adult vaccines (Shingrix, Tdap, hepatitis A) are Part D benefits with zero cost-sharing under IRA 2022 effective January 1, 2023.

10. Assuming Medicare Advantage offers identical preventive coverage. Medicare Advantage plans must cover the same preventive services as Original Medicare with zero cost-sharing for the IPPE, AWV, and USPSTF Grade A/B services. MA plans may charge cost-sharing on diagnostic follow-up tests but cannot charge for the covered preventive services themselves.

11. Missing the connection between IPPE/AWV and downstream screenings. The IPPE and AWV are not just standalone visits: they include referrals for AAA screening, cardiovascular blood tests, depression screening, and other linked services. Some screenings (AAA) require an IPPE/AWV referral to qualify for coverage.

12. Forgetting advance care planning is covered as part of AWV. Advance care planning (HCPCS G0444) furnished as part of the AWV is no-cost-sharing. ACP furnished separately is subject to Part B cost-sharing.

13. Not reporting tobacco use. Tobacco use cessation counseling (HCPCS G0436, G0437) is a covered preventive service with no cost-sharing for symptomatic and asymptomatic users. Beneficiaries should disclose current tobacco use to qualify for counseling.

14. Believing that high-risk frequency rules are automatic. Beneficiaries must meet defined high-risk criteria to qualify for the more frequent screening intervals (for example, annual pap if high-risk; 24-month colonoscopy if high-risk for colorectal cancer).

::: accordion

What is the difference between the Welcome to Medicare visit and the Annual Wellness Visit?

The Welcome to Medicare Initial Preventive Physical Examination (IPPE) is a once-in-a-lifetime visit available during the first 12 months of Part B enrollment under Section 1861(s)(2)(W). The Annual Wellness Visit (AWV) is available annually after 12 months of Part B under Section 1861(hhh). Both have zero cost-sharing under ACA Section 4104. The IPPE is broader; the AWV focuses on health risk assessment and personalized prevention planning.

Does Medicare cover an annual physical exam?

No. Medicare does not cover a traditional annual physical exam. Medicare covers the IPPE (once-in-a-lifetime within the first 12 months of Part B) and the AWV (annual thereafter), both with zero cost-sharing. Many practices combine the AWV with an E/M visit for chronic care, but the E/M portion is billed separately and is subject to Part B cost-sharing.

Are all preventive services free under Medicare?

No. ACA Section 4104 zero cost-sharing applies to the IPPE, AWV, and USPSTF Grade A or B preventive services when the provider accepts assignment. Some Section 1861 benefits remain subject to Part B cost-sharing, including diabetes self-management training (DSMT) and medical nutrition therapy (MNT). If a preventive service is converted to diagnostic (for example, polyp removal during screening colonoscopy), cost-sharing applies (though phased to 0% by 2030 for screening colonoscopy).

How often does Medicare cover screening mammography?

Annual screening mammography is covered for women age 40 and older under Section 1834(c). Baseline mammography is covered for women age 35 through 39. HCPCS 77067 (screening mammography, bilateral) is billed. Zero cost-sharing applies.

How often does Medicare cover screening pap/pelvic?

Section 1861(nn) covers screening pap smear and pelvic exam every 24 months for women at standard risk. Women at high risk (history of cervical cancer or recent abnormal pap) qualify every 12 months. Zero cost-sharing applies.

How often does Medicare cover colonoscopy?

Screening colonoscopy is covered every 10 years for average-risk beneficiaries and every 24 months for high-risk under Section 1834(d). Other colorectal screening tests have different frequencies: FOBT/FIT annually, Cologuard every 3 years, flex sig every 4 years, CT colonography every 5 years. Zero cost-sharing applies to most services; coinsurance phases down for screening colonoscopy converted to diagnostic.

Why am I charged coinsurance when my screening colonoscopy detected a polyp?

When a screening colonoscopy results in polyp removal, the visit converts from screening to diagnostic, triggering coinsurance under historical rules. The Bipartisan Budget Act of 2018 Section 50403 and CAA 2021 Section 122 phase down the coinsurance: 15% in 2023-2026, 10% in 2027-2029, 0% in 2030 and after.

Does Medicare cover bone density scans?

Yes. Section 1861(jj) covers bone mass measurement (DEXA, quantitative ultrasound, quantitative CT, single-energy X-ray) every 24 months for risk-based eligibility, more frequent if medically necessary. HCPCS 77080 for axial DEXA. Zero cost-sharing applies.

Who is eligible for AAA screening?

Section 1861(yy) covers a once-in-a-lifetime ultrasound screening for abdominal aortic aneurysm for men age 65 to 75 who have ever smoked, and for men or women age 65 to 75 with a family history of AAA. The screening must be referred via an IPPE or AWV. Zero cost-sharing applies.

Does Medicare cover lung cancer screening?

Yes. Lung cancer screening with low-dose computed tomography (LDCT) is covered annually for eligible smokers under Section 1861(ddd) authority. Eligibility: age 50-77, 20+ pack-year smoking history, current smoker or quit within 15 years, asymptomatic. A shared decision-making visit (HCPCS G0296) is required before the first screening. HCPCS G0297 for the LDCT. Zero cost-sharing applies.

Does Medicare cover diabetes screening?

Yes. Section 1861(uu) covers diabetes screening blood tests annually for individuals with risk factors and twice annually for high-risk individuals. Fasting plasma glucose, post-glucose challenge test, or hemoglobin A1c may be used. Zero cost-sharing applies.

Does Medicare cover cardiovascular disease screening?

Yes. Section 1861(ggg) covers cardiovascular screening blood tests every 5 years. Total cholesterol, HDL, triglycerides are included. Zero cost-sharing applies.

What vaccines are covered under Medicare without cost-sharing?

Under Part B: influenza vaccine (annual), pneumococcal vaccine (PCV20 or sequential PCV15+PPSV23 per ACIP), hepatitis B vaccine (for high-risk and intermediate-risk), and COVID-19 vaccine. Under Part D effective January 1, 2023 (IRA 2022 Section 11401): all ACIP-recommended adult vaccines including Shingrix, Tdap, hepatitis A, etc.

Does Medicare cover obesity counseling?

Yes. Intensive behavioral therapy for obesity is covered under Section 1861(ddd) authority for beneficiaries with BMI of 30 or greater. The benefit includes weekly counseling visits for the first month, biweekly for months 2 through 6, and monthly for months 7 through 12 if certain progress criteria are met.

Does Medicare cover tobacco cessation counseling?

Yes. Tobacco use cessation counseling is covered for all tobacco users under Section 1861(ddd) authority. Up to 8 counseling sessions per 12-month period; 2 cessation attempts per year. HCPCS G0436, G0437. Zero cost-sharing.

Does Medicare cover depression screening?

Yes. Depression screening in the primary care setting is covered annually under Section 1861(ddd) authority. HCPCS G0444. Zero cost-sharing when furnished in primary care.

What is diabetes self-management training (DSMT)?

DSMT under Section 1861(qq) covers up to 10 hours of initial training in the first year following diabetes diagnosis and 2 hours of follow-up annually. Furnished by ADA-recognized or AADE-accredited programs. DSMT IS subject to Part B deductible and 20% coinsurance (not on the ACA zero-cost-sharing list).

Does Medicare cover medical nutrition therapy (MNT)?

Yes, but in limited circumstances. Section 1861(vv) covers MNT for diabetes and renal disease. Furnished by a registered dietitian or nutrition professional. Subject to Part B cost-sharing.

How do I know if my provider accepts assignment?

A Medicare-participating provider accepts assignment for all Medicare-covered services. You can verify by calling Medicare (1-800-MEDICARE), using the Medicare.gov physician finder, or asking the practice billing office directly. The zero-cost-sharing preventive benefit requires assignment.

What if I get charged for a service that should be free?

If you believe you were incorrectly charged for an IPPE, AWV, or USPSTF Grade A/B preventive service, first contact the provider's billing office. If unresolved, file a Medicare appeal with Palmetto GBA (Georgia's MAC) at 1-877-567-9230. The Medicare appeals process has 5 levels: redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and federal court.

Does Medicare Advantage cover the same preventive services?

Yes. Medicare Advantage plans must cover the same preventive services as Original Medicare with zero cost-sharing for the IPPE, AWV, and USPSTF Grade A/B services. MA plans may impose cost-sharing on diagnostic follow-up tests and may use prior authorization, but cannot charge for the covered preventive services themselves.

What is the United States Preventive Services Task Force?

The USPSTF is an independent panel of national experts in disease prevention and evidence-based medicine. The USPSTF grades preventive services A through D and "I" (insufficient evidence). Section 1861(ddd) of the Social Security Act authorizes the HHS Secretary to add USPSTF Grade A or B services to Medicare coverage.

Can I get preventive services at a Federally Qualified Health Center in Georgia?

Yes. Georgia has more than 30 FQHC organizations operating over 200 sites statewide. FQHCs accept Medicare and provide preventive services as part of comprehensive primary care. To find a Georgia FQHC, call HRSA at 1-877-464-4772.

Where can Georgia families get help with Medicare preventive services questions?

GeorgiaCares (the State Health Insurance Assistance Program) provides free Medicare counseling at 1-866-552-4464. Medicare Rights Center (1-800-333-4114) offers free national counseling. Palmetto GBA (1-877-567-9230) handles Medicare Part B claims for Georgia. :::

::: cta Get help understanding your Georgia Medicare preventive services coverage.

Brevy's eldercare guides at brevy.com help Georgia families understand the federal statutory framework for Medicare preventive services, the zero-cost-sharing benefit, screening frequency rules, and how to find Medicare-participating preventive care providers across Georgia. Below are key contacts for preventive services questions, complaints, and appeals.

Medicare and Federal Resources:

• Medicare general inquiries: 1-800-MEDICARE (1-800-633-4227)
• Medicare.gov for plan finder, provider search, and preventive services schedules
• Palmetto GBA Jurisdiction J (Georgia Part B Medicare Administrative Contractor): 1-877-567-9230
• KEPRO (Georgia Quality Improvement Organization, appeals): 1-844-455-8708
• Social Security Administration (Medicare enrollment): 1-800-772-1213
• HHS Office for Civil Rights: 1-800-368-1019
• HHS Office of Inspector General (fraud hotline): 1-800-447-8477
• HRSA Find a Health Center (FQHC directory): 1-877-464-4772

Georgia State Resources:

• GeorgiaCares (SHIP free Medicare counseling): 1-866-552-4464
• Georgia DCH Medicaid Member Services: 1-866-211-0950
• Georgia Department of Public Health: 404-657-2700

Advocacy and Legal Assistance:

• Medicare Rights Center (national free counseling): 1-800-333-4114
• Center for Medicare Advocacy: 1-860-456-7790
• Atlanta Legal Aid Society: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469

Community and Information Services:

• 211 Georgia: dial 211
• Eldercare Locator: 1-800-677-1116
• VA Benefits: 1-800-827-1000

This guide is informational, not legal or medical advice. Medicare preventive services rules, frequency limits, and cost-sharing amounts change annually. Always verify current coverage with Medicare.gov or 1-800-MEDICARE before scheduling care, and consult a qualified physician or benefits counselor for advice on your specific situation. :::