Does Medicare Cover Annual Physicals?

Medicare Wellness Visit vs. Annual Physical

Does Medicare cover a physical exam? The short answer is no, but it does cover a wellness exam.  Here’s a question for you, “what’s the difference between a Medicare Annual Wellness visit versus an Annual Physical, and which one is covered by Medicare?”

Before your head explodes, take a minute and read the following list of procedures and measurements that make up these two completely separate doctor visits and we’ll point out the subtle difference between them.  Or call us to discuss what is covered and how it will affect you 844-528-8688.

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Health insurance can be very confusing for most seniors. It’s bad enough that there are acronyms that must be learned, coinsurance percentages, silver, gold, and bronze plans; now we have to learn what’s actually included in different procedures.

Important Medicare Terms

• Deductible: This is the amount that you’ll pay out-of-pocket before Medicare coverage kicks in.
• Copayment: This represents the flat dollar amount you’ll need to pay for certain healthcare services. This is generally required when you purchase retain prescription drugs under Medicare Part D.
• Coinsurance: This is the self-insurance percentage that you will be required to pay for treatments under Medicare Part B

What is an Annual Physical?

An annual physical is what most people are accustomed to. It is more “hands-on” and includes diagnostic testing if your physician deems it necessary. A physical is considered to be more comprehensive and is not covered by Medicare Part B like a Wellness Visit is. Here’s what you can expect from your health care provider:

• Height, weight, and BMI measurement
• Blood pressure measurement
• The doctor will review your medical history and your family’s medical history (you provide this information in a questionnaire)
• Check vital signs (typically includes temperature, pulse, respiration,  and blood pressure)
• Check your lungs
• Perform a neck and head exam
• Perform a neurological exam
• Perform an abdominal exam
• Test your reflexes
•  Order urine and blood samples for testing

What is a Medicare Wellness Visit?

According to Medicare.gov, a “Wellness Visit” is covered once you’ve had Medicare Part B for longer than 12 months. If you have, you can get a “Wellness Visit” on an annual basis at no cost as long as the physician administering the exam accepts Medicare assignment. Also, there is NO Part B deductible or coinsurance applied.

However, and this is a big “however,” the Part B deductible might apply and you could have to pay coinsurance if your health care provider performs additional services or tests during your Wellness Visit and if any additional tests or services are not covered under the Medicare preventive benefits. If this “however” statement is even more confusing then check out what services and tests are covered under the Medicare Wellness visit:

• Your doctor will review your medical history and your family’s medical history (you provide this information on a questionnaire).
• Your doctor will begin developing or updating a current list of health care providers and any prescription drugs that have been subscribed (you provide this information on a questionnaire).
• Your doctor or nurse will measure your weight, height, blood pressure, and other routine measurements (other routine measurements is not defined)
• The doctor will attempt to determine if you have any cognitive impairment
• Your doctor will provide personalized health advice
• Your doctor will provide a list of health risk factors and recommended treatments
• Your doctor will provide a checklist (schedule) of preventive services that he or she recommends
• Finally, your doctor will discuss advance care planning with you

As we mentioned earlier, the Wellness Visit is covered under Medicare Part B and your deductible will not apply.

There is some good news, however. You actually do not have to wait until you’ve had Medicare Part B for 12 months before you can get checked out by your doctor. Medicare has a “Welcome to Medicare” preventive visit that you can take advantage of within the first 12 months of Part B coverage.

What is the “Welcome to Medicare” Preventive Visit

The Welcome to Medicare preventive visit is kind of a “scaled-down” Wellness Visit that allows your physician to set up a “baseline” for your medical condition. 

Medicare Part B will pay 100% of the preventive visit as long as your doctor accepts assignment of Medicare. You could be charged coinsurance if your doctor performs additional services or tests that are outside the limits of the Welcome to Medicare preventive visit. Here’s what you’ll get:

• The doctor will do certain screenings, give you the flu and pneumococcal shot if needed and refer you for additional care if necessary.
• Check your height, weight, and blood pressure.
• Calculate your body mass index (BMI)
• Perform a simple vision test (not an eye exam)
• Discuss any risk for depression and your safety level
• Ask you about creating advance directives
• Provide you a list of which screenings, vaccines, and other preventive services you need.

It’s important that when you make your appointment, you tell the doctor’s office that you want to schedule your “Welcome to Medicare” preventive visit so the doctor’s office is aware of the services they should provide.

Still Not Sure? Here’s the Bottom Line

In my opinion, unless you compare the services offered in each type of visit side-to-side, you’ll likely still be unsure of what is paid for and what services are included. Here’s the bottom line:

Comprehensive Physical Exam – Not paid for by Medicare Part B and typically not paid for by Medigap.

Wellness Visit – 100% paid for by Medicare as long as your health care provider accepts assignment and does not go outside the services and tests covered under a Wellness Visit. Must have been enrolled in Medicare Part B for 12 months or more.

Health insurance can be very confusing for most seniors. It’s bad enough that there are acronyms that must be learned, coinsurance percentages, silver, gold, and bronze plans; now we have to learn what’s actually included in different procedures.

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