Medicare ‘Physicals’ are Not What You Expect 

We get calls and emails throughout the year from Medicare subscribers who have traditionally had their physician perform a comprehensive annual physical. They are surprised after transitioning into Medicare, when they receive a bill from their doctor’s office indicating that they need to pay out of pocket for the physical exam they recently received. To the average individual reaching Medicare eligibility the “Welcome to Medicare” preventative visit, the “Annual Wellness” visits and annual physical examinations may sound like the same procedure, but they differ in when the benefits apply and how the benefits are paid.

• Annual Physicals are comprehensive examinations. At an annual physical a physician will typically:

  • Measure height and weight.
  • Take your blood pressure.
  • Measure BMI.
  • Review your medical and family history.
  • Assess your risk factors for preventable diseases.
  • Check vital signs.
  • Perform head and neck exam.
  • Perform lung exam.
  • Perform abdominal exam.
  • Perform neurological exam.
  • Test your reflexes.
  • Submit urine and blood samples for lab testing.

Medicare will not pay for this type of annual physical. A Medicare beneficiary can still choose to have this exam performed annually but will pay out of pocket for the service.

• Welcome to Medicare preventative visit only happens once and must be completed within 12 months of an individual’s enrollment in Medicare Part B. The goal is to determine the current state of an individual’s medical and social health history related to one’s overall health. The health care provider educates and counsels the new Medicare beneficiary on recommendations for preventive services. This appointment may include a questionnaire that checks for any cognitive impairment at the beneficiary’s request. If your provider accepts Medicare assignment, there are no copays or coinsurance and the Part B deductible does not apply unless the provider orders additional tests or services or any other items not covered by Medicare.

• Annual Wellness visits are available once each year after the second year following an individual’s enrollment in Medicare Part B. These visits serve the same purpose as the “Welcome to Medicare” visit but include any health history updates, detection of any cognitive impairment, personalized health advice, a list of any risk factors one may have and treatment options, and a screening schedule for preventive services. If your provider accepts Medicare assignment, coinsurance and the Part B deductible may apply if the provider performs additional tests or services during the same visit whether covered or not covered by Medicare.

• “Medicare Wellness” exams include the assessments, but none of the hands-on tests where the doctor physically touches you. Under Medicare, a doctor will only perform these types of services if there is a specific diagnosis or symptom that necessitates that type of examination. Other preventive services will be scheduled, but not performed, during your exam. During a “Medicare Wellness” exam a physician will typically:

  • Measure height, weight, blood pressure and other routine measurements.
  • Review your medical and family history.
  • Assess your risk factors and treatment options.
  • Review Health Risk Assessment questionnaire
  • Update your list of providers and prescriptions.
  • Look for signs of cognitive impairment.
  • Set up a screening schedule for appropriate preventive services.

• The Medicare Advantage Exception: Most Medicare Advantage (Part C) plans include an annual physical examination along with the preventive and screening services.
To get information on which preventative and screening services are covered by Medicare click the link below: https://www.medicare.gov/coverage/preventive-screening-services.