Medicare's coverage for annual visits
Original Medicare (Parts A and B) does not cover standard annual physical exams, which are performed without a specific diagnosis or treatment in mind. However, Medicare does cover specific preventive visits:
- The Initial Preventive Physical Examination (IPPE): New Medicare Part B beneficiaries can get this one-time "Welcome to Medicare" visit within their first 12 months. It includes a health history review, basic physical measurements, and a discussion about future preventive care.
- The Annual Wellness Visit (AWV): After the first year, Medicare Part B covers an AWV every 12 months. This visit focuses on creating or updating a personalized plan to help you stay healthy and is not a physical exam. It is free if your doctor accepts Medicare assignment.
What to expect at an Annual Wellness Visit
An AWV is focused on preventive care planning. Key components include:
- A Health Risk Assessment questionnaire.
- Recording of height, weight, BMI, and blood pressure.
- Review of medical and family history.
- Cognitive assessment.
- Creation or update of a personalized prevention plan, including screening recommendations.
- Optional discussion of advance care planning.
- Review of current medications.
The difference between a physical and a wellness visit
The key difference lies in their purpose. A physical is a comprehensive exam to check for signs of illness, often including hands-on checks and lab tests. An AWV is a planning session focused on prevention, risk assessment, and creating a health plan. It typically does not involve a full physical exam or diagnostic lab tests, though referrals may be made. While a physical exam with Original Medicare is paid 100% out-of-pocket, an AWV is free if the provider accepts assignment and no other services are rendered.
Potential out-of-pocket costs
The AWV itself is free, but other services during the visit can incur costs.
- Additional Services: If you discuss a medical problem during your AWV, that part of the visit may be billed separately, subject to your Part B deductible and 20% coinsurance.
- Lab Tests and Screenings: Tests recommended during your AWV are billed separately and may have associated costs depending on the service.
- Medicare Advantage: These plans cover the AWV and some may offer coverage for routine annual physicals. Check your plan for network rules and specific benefits.
Conclusion
Original Medicare does not cover routine annual physicals. It covers a one-time IPPE and a yearly AWV for prevention and risk assessment, with no cost if the provider accepts assignment. Physical exams are billed as standard office visits. To avoid unexpected costs, schedule a "Medicare Annual Wellness Visit" specifically and discuss billing with your provider if you have other health concerns. You can find more information on Medicare.gov.
