Does Medicare Cover Annual Physicals?

Original Medicare does not cover routine annual physicals. Any outpatient exams that Medicare approves based on your doctor’s recommendation would be subject to the Part B deductible and 20% coinsurance.

If you participate in a Medicare supplement plan, you may be eligible for full or partial coverage of the coinsurance. Many Medicare Advantage (MA) plans cover a no-fee annual physical within network and a percentage of the cost out-of-network.

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Why Medicare Does Not Cover the Annual Physical Exam

The importance of preventive care cannot be underestimated. Citing the Centers for Disease Control (CDC), seven out of 10 deaths in the United States are caused by conditions categorized by the medical community as preventable.

Preventive screenings and consultations present an opportunity to identify markers of chronic disease and infections that may be treatable, potentially expanding life expectancy and/or quality of life.  

However, many people confuse an annual wellness visit (AWV) with a physical exam. An annual physical exam is a much more comprehensive visit. It typically includes bloodwork and other diagnostic testing services which are not included in a wellness visit.

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Preventive Visit Within the First Year

Medicare Part B covers the cost of visits to the doctor as well as outpatient care, home health care, durable medical equipment and mental health services. Within the first 12 months of enrollment in Part B, you are eligible to see your doctor for what Medicare refers to as the Welcome to Medicare preventive visit.

These preventative services include the following:

• Review of medical history and health-related social history.
• Education and consultation regarding preventive services.
• Referrals for other health care services if applicable.

As long as the qualified healthcare practitioner accepts assignment, this is a free one-time visit. Assignment means that the provider has agreed to accept the payment received directly from Medicare and refrain from billing you beyond any deductible or coinsurance that may be due. When you schedule the appointment and state your request for a “Welcome to Medicare preventive” visit, no charges should be applied.

If your doctor conducts tests or performs services beyond the preventive benefits listed above, then the deductible and coinsurance may apply. If you have a routine physical exam during this time, it may not be covered at all because it is outside the parameters of services for this type of visit.

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Medicare Wellness Visits

A yearly wellness visit is a benefit available to Medicare recipients who have been enrolled in Part B for over 12 months. The purpose of this visit is to construct or update a plan specific to your health status. Based on any health and risk factors present, the intent of this plan is to prevent disease or disability.

What’s typically checked during your AWV:

• Family and personal medical history
• Review of prescription medications
• Height
• Weight
• Blood pressure
• Heart rate
• Body temperature
• Risk factors that are indications of possible future illness
• Recommend preventive tests and services such as vaccinations and mammograms

When scheduling the appointment, be sure to state that you would like your yearly wellness visit. These annual Medicare wellness visits are free of charge as long as your qualified healthcare practitioner accepts assignment and does not perform any additional services beyond the scope defined by Medicare.

What is not covered in a Medicare annual wellness visit:

• Bloodwork
• Urinalysis
• Diagnostic testing services

As in the Welcome to Medicare preventive visit, a physical exam is excluded. However, the physician may administer a cognitive impairment assessment to identify any signs of dementia or Alzheimer’s disease. Completing a health risk assessment is part of this visit as well as a review of preventive services and any referrals needed.

The one-time Welcome to Medicare preventive visit is not a prerequisite for the yearly wellness visit, but the annual cannot occur until you have passed the 12-month mark for Part B enrollment.

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