This expanded coverage, as established at 42 CFR 410.15, is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS), when performed by qualified health professionals, for an individual who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare coinsurance and Part B deductibles do not apply.
The AWV will include the establishment of, or update to, the individual’s medical/family history, measurement of his/her height, weight, body-mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B. Definitions relative to the AWV are included below.
Coverage is available for an AWV that meets the following requirements:
1. It is performed by a health professional; and,
2. It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.
Sections 4103 and 4104 of the ACA also provide for a waiver of the Medicare coinsurance and Part B deductible requirements for an AWV effective for services furnished on or after January 1, 2011.
Definitions Relative to the AWV:
Detection of any cognitive impairment
: The assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient reports, concerns raised by family members, friends, caretakers, or others.
Eligible beneficiary:
An individual who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period and who has not received either an IPPE or an AWV providing PPPS within the past 12 months.
Establishment of, or an update to, the individual’s medical/family history
: At a minimum, the collection and documentation of the following:
a. Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments.
b. Use or exposure to medications and supplements, including calcium and vitamins.
c. Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.
