Medicare and Annual Wellness Visits

Including a Glossary of Helpful Terms

Taking time to schedule an annual visit with your Primary Care Physician (PCP) could be life-changing because prevention is often the key to living longer, healthier lives.

Even if seniors are feeling well or taking very few medications, getting an Annual Wellness Visit can help your PCP identify symptoms and conditions early.

Q: Does Medicare require patients to visit their PCP annually?

A: Medicare does not require patients to visit their PCP annually. However, they do encourage patients to schedule an Initial Preventive Physical Examination (“Welcome to Medicare Visit”) within the first 12 months of part B enrollment to review medical and social health histories as well as preventive services education.

Medicare also encourages an “Annual Wellness Visit” every 12 months to develop or update a personalized plan for prevention of illness and perform a health risk assessment. During an Annual Wellness Visit, vitals are obtained, but a complete physical exam is not performed.

Q: Are “annual physicals” covered by insurance providers, including Medicare?

A: Medicare covers the Welcome to Medicare Visit and the Annual Wellness Visit, with no co-pay or deductible, but Medicare does not cover routine annual physicals during which more detailed exams are performed and which often include routine lab and screening tests.

Some supplemental insurance plans may cover routine annual physicals, with applicable co-pays and deductibles. Medicare will cover services for specific diagnoses with necessary labs/testing, but co-pays and deductibles will apply.

Q: What tests are typically part of an annual physical?

A: Tests are determined based on a patient’s age, medical history, family history, risk factors and presenting complaints. Often, labs are ordered to monitor blood sugar, electrolytes, kidney and liver function, blood counts, cholesterol, and thyroid function. Screening for osteoporosis, breast cancer, colon cancer, cervical cancer, prostate cancer, and lung cancer are also discussed and ordered as appropriate.

Q: Are these tests usually covered by insurance?

A: Many preventive services are covered by health insurance plans; however, patients are encouraged to check with their insurance companies before completing any lab or testing to see if it is covered, and how much out-of-pocket cost there will be.

Q: For people who are looking for a PCP, is there a trusted online resource for checking to see how a physician is rated?

A: There is a lot of information available online, but the most reliable, trustworthy resources would be a patient’s insurance company review or local hospital websites. These sources have firsthand information about physicians who have gone through rigorous credentialing processes and are highly recommended.

A Glossary of Helpful Terms Regarding Medicare and Checkups

Annual Physical An annual physical exam is an assessment of your body’s overall health. The primary purpose is to look for health problems.

During the exam, your doctor uses his or her senses to evaluate how your body is performing. Based on the evaluation, your doctor may ask you to have tests to determine or rule out possible health problems.

 The list below shows some actions your physician may take during a physical exam.

  • Visually check your body for signs of existing health issues
  • Look into your eyes, ears, nose, and throat for potential problems
  • Listen to your heart and lungs to detect irregular sounds
  • Touch parts of your body to feel for abnormalities
  • Test your motor function and reflexes
  • Complete pelvic and rectal exams
  • Measure your height, weight, and blood pressure

Medicare does not cover an annual physical. The exam and any tests your doctor orders are separate services, and you may have expenses related to these depending on your Medicare plan.

Annual Wellness Visit A Medicare Wellness Visit is an overall evaluation of your health and well-being. The primary purpose is prevention and involves either creating or updating your individual prevention plan. Medicare covers a Wellness Visit once every 12 months (11 full months must have passed since your last Wellness visit), and you are eligible for this benefit after having Medicare Part B for at least 12 months.

During the exam, your primary care provider combines information from the visit with your medical record to assess your risk for common preventable health problems, such as heart disease, cancer, and type 2 diabetes. Based on the evaluation, your doctor creates your individual prevention plan with a checklist of screenings you need to have.

The list below shows actions your provider may perform during a wellness exam.

  • Review your health risk assessment (questions you answer about your health)
  • Confirm your medical and family history
  • Document your current prescriptions and providers
  • Measure and document your height, weight, and blood pressure
  • Look for signs of memory loss, dementia, or frailty
  • Record your health risk factors and treatment options
  • Provide personalized health advice
  • Develop a schedule for the preventive services recommended for you

Medicare Part B covers an annual wellness exam and several preventive screenings with no copay or deductible. However, you may have to pay a portion of the cost for some recommended tests or services.

Copay An amount you are required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or prescription medication. This is generally a flat dollar amount rather than a percentage.

Coinsurance An amount you are required to pay as your share of the cost for services after you pay any deductibles and is usually a percentage.

Deductible The amount you are required to pay for health care or prescriptions before Medicare, your prescription drug plan, or any other insurance will pay.

Preventive Services Health care to prevent or detect illness at an early stage. Preventive services include pap tests, certain vaccines, and screening mammograms.

Routine Labs and Screenings Testing or services recommended by a health care provider that allow potential health problems to be prevented or addressed early enough for a better overall outcome of a patient’s health.

Supplemental Insurance Plan (also known as Medigap) refers to numerous private health insurance plans used to supplement Medicare. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare covered services

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Advanced Beneficiary Notice (ABN) A waiver that a physician or supplier should give a Medicare beneficiary when providing an item or service for which Medicare is expected to deny payment.

If you do not receive an ABN before you get the service from your physician or supplier, and Medicare does not pay for it, then you probably do not have to pay for it (unless it is a statutory exclusion).

If the physician or supplier does provide you an ABN that you sign prior to receiving the service, and Medicare does not pay for it, then you will have to pay your physician or supplier for it.

ABNs only apply if you have Traditional Medicare. They are not applicable if you are in a Medicare Managed Care Plan or Private Fee-for-Service Plan.

Coordination of Benefits (COB) Method for determining the responsibilities of two or more health plans that have some financial responsibility for a medical claim.

Explanation of Benefits (EOB) Statement from your health insurance detailing what costs will be covered for medical care or services received. This generally will include the total cost of the care received as well as any out-of-pocket expenses that the patient may incur.

Statutory Exclusion Services or supplies never covered by Medicare. Some examples are dental services, routine foot care, and cosmetic surgery.

Schedule an annual visit with your primary care physician today. 

To find a St. Joe’s primary care physician visit https://www.stjoeshealth.org/find-a-doctor/