Tabitha Wittstock: Population Health Coordinator
Stephanie Ketchum, LPN: Population Health Nurse, Primary Chronic Care Management nurse
Hailie Stone, MA: Population Health Nurse
What is Population Health?
Population health refers to the health status and health outcomes within a group of people rather than considering the health of one person at a time.
What do we do?
—Medicare Annual Wellness Visits: A yearly office visit, used to help identify and reduce health risks.
• The Initial Preventive Physical Exam (IPPE), also known as the “Welcome to Medicare” Preventive Visit, promotes good health through disease prevention and detection. Medicare will pay for 1 patient IPPE per lifetime no later than the first 12 months after Part B benefits eligibility date.
o This visit offers a “once-in-a-lifetime screening electrocardiogram (ECG), as appropriate.”
o Appropriate screenings and other preventive services covered by Medicare Part B benefits.
• The Annual Wellness Visit is a FREE BENEFIT to anyone enrolled in Medicare with Part B benefits. This visit is completed 12 months following the “Welcome to Medicare,” and annually thereafter. Annual Wellness Visits have been proven to *lower your health care costs *learn how to make minor changes in your lifestyle to keep you healthy *detect diseases early, before they become a problem *review your medical conditions and current list of medications, vitamins, and supplements *review the preventative care items and see that these are up to date
Examples of qualifying chronic conditions include, but are not limited to, the following:
• Alzheimer’s disease and related dementias
• Arthritis
• Asthma
• Atrial fibrillation
• Cancer
• Cardiovascular disease
• Chronic obstructive pulmonary disease
• Depression
• Substance use disorders
• Diabetes
• Hypertension
• Infectious diseases such as HIV/AIDS.
-CCM Services may include
• At least 20 minutes a month of chronic care management services
• Coordination of care between your pharmacy, specialists, testing centers, hospitals, and more • Updated and regular communication with your doctor to inform them of resources you may need for support
• Phone check-ins between visits to keep you on track
• 24/7 emergency access to health care professionals to keep them updated on changes in your health and answer any of your questions or concerns
• Personalized assistance from dedicated health care professionals who will work with you to create your care plans
• Expert assistance with setting and meeting your health goals
• Assistance with finding transportation to/from appointments as needed
• Referral coordination
• Patient assistance
—Monthly Health Initiatives
*Will update to include our monthly initiatives/screenings/discounted pricing on related tests, etc.
—Provide Information and Resources on the following:
• Advanced Care Planning
• Transportation Resources
• Medicare Coverage of DME, Diabetic Supplies, and more
• Community Resources
• Medicare Preventive Screenings and Recommendations
**see Medicare Learning Network’s booklet for complete list and information: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html
• Screening Mammogram:
o Women with Medicare Part B ages 40+
o Zero coinsurance/deductible applied
o Annually
• Lung Cancer Screening
o Patients with Medicare Part B who meet ALL the following criteria:
Age 50-77
Asymptomatic
Current smoker or quit < 15 years ago
History of smoking 20 pack years or more
• (Pack years = number of years x packs smoked per day)
o Annually for qualifying patients
• Bone Density Measurement
o Patients with Medicare Part B who meet 1 of the following criteria:
Women whose physician or qualified practitioner determines them estrogen-deficient and at clinical osteoporosis risk
People with vertebral abnormalities
People getting (or expecting to get) glucocorticoid therapy for more than 3 months
People with primary hyperparathyroidism
People monitored to assess FDA-approved osteoporosis drug therapy response
o Every 2 years for qualifying patients
o Zero coinsurance/deductible applied
• Colon Cancer Screening
**Effective January 1, 2023, if the patient initially has a non-invasive stool-based screening test (FOBT or MT-sDNA test) and gets a positive result, we also cover a follow-up colonoscopy as a screening test. The patient pays nothing for the screening test if their doctor or other qualified health care provider accepts assignment.
o Colorectal cancer screening using MT-sDNA and blood-based biomarker tests:
Patients with Medicare Part B who meet these criteria:
• Aged 45–85 years
• Asymptomatic
• At average colorectal cancer risk
o Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies:
Patients with Medicare Part B who meet at least 1 of these criteria:
• Aged 45 and older at normal colorectal cancer risk (there is no minimum age requirement for screening colonoscopies)
• At high colorectal cancer risk
o Personal history of colon cancer
o Family history of colon cancer
o Inflammatory bowel disease, Ulcerative Colitis, Crohn’s Disease
• Screening Ultrasound for Abdominal Aortic Aneurysm (AAA)
o Patients with Medicare Part B who meet 1 of the following criteria:
Family history of AAA
Male age 65-75 with a history of smoking 100 cigarettes or more in his lifetime
o Once per lifetime
o Zero copay/coinsurance or deductible applied
• Hepatitis C Screening
o Patients with Medicare Part B who meet 1 of the following criteria
Born between 1945-1965
Received a blood transfusion before 1992
are considered high risk due to current or past history using federally prohibited, injectable substances
o Zero copay/coinsurance or deductible applied
o Once per lifetime
If Medicare considers you at high risk, you also qualify for yearly screenings following the initial screening
• Lipid Panel as Screening for Cardiovascular Disease
o Patients with Medicare Part B without signs/symptoms of apparent cardiovascular disease
o Once every 5 years
o Zero coinsurance/copay or deductible applied
• Shingrix Vaccine (shingles prevention)*newly covered in 2023
o 2-part vaccine. Each dose administered 2-6 months apart
o Zero coinsurance/copay or deductible applied with Medicare Part D Coverage
• Tetanus Vaccine *newly covered in 2023
o Recommended once every 10 years
o Zero coinsurance/copay or deductible applied with Medicare Part D coverage if administered as a preventive vaccine
* see Medicare Learning Network’s booklet on Part D Vaccine coverage: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/vaccines-part-d-factsheet-icn908764.pdf
• COVID 19 Vaccines
o Patients with Medicare Part B coverage
o As recommended by CDC
o Zero coinsurance/copay or deductible applied
• Pneumonia Vaccines
o Patients 65+ with Medicare Part B coverage
o As recommended by CDC
• Flu Vaccine
o Patients with Medicare Part B coverage
o Once per flu season
More often if deemed medically necessary
• Prostate Cancer Screening
o Men age 50+ with Medicare part B coverage
o Annually
PSA lab draw
• Zero copay/coinsurance or deductible applied
Digital rectal exam
• Copay/coinsurance and/or deductible apply
• Screening Pelvic Exam (includes a clinical breast exam)
o Women with Medicare Part B coverage
o Zero coinsurance/copay or deductible applied
Annually for high risk patients or those with an abnormal pap in the past 3 years
Every 2 years for low risk women
• Cervical Cancer Screening (HPV)
o Women with Medicare Part B coverage who meet the following criteria
Age 30-65
Asymptomatic
Zero coinsurance/copay or deductible applied
Every 5 years
• Electrocardiogram (ECG):
**an electrocardiogram records the electrical signal from the heart to check for different heart conditions.
o Patients with Medicare Part B coverage offered only as part of the “Welcome to Medicare” or IPPE visit.
o Once per lifetime
o Zero coinsurance/copay or deductible applied