Does Medicare Cover Annual Physicals?

Q. My sister Amy, 66, recently called her primary care doctor’s office to schedule an annual checkup. She naturally assumed her Medicare coverage would pick up most, if not all, of the tab for the exam. After all, an annual visit is supposed to be covered. To Amy, the appointment seemed like a routine physical. She was particularly pleased that the doctor spent a lot of time with her, so she recommended him to all of her friends. That was, until she got the hefty bill in the mail.

Amy called the doctor’s office assuming there was a billing error. To her surprise, it was no error. She was informed that Medicare does not cover an annual physical exam! In fact, federal law prohibits the health care program from paying for annual physicals, and patients who get them may be on the hook for the entire amount! But Medicare enrollees pay nothing for an “annual wellness visit,” which the program covers in full as a preventive service.

What should actually be included as part of the annual Medicare-covered wellness visit as opposed to an annual physical? How do I ensure that my Medicare-covered annual wellness visit doesn’t end up being a complete physical that I have to pay for out of pocket?

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A. Preventive care is the care that you receive to prevent illness, detect medical conditions, and keep you healthy. According to Medicare.gov, Medicare covers Annual Wellness Visits, which focus primarily on preventative care, which includes screenings, vaccines, and counseling. Everyone enrolled in Medicare is eligible for an Annual Wellness Visit at no additional cost.

Much to the surprise of many Medicare enrollees, an annual “physical” is not the same as the Annual Wellness Visit covered by Medicare. A physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight, and blood pressure.

What is Included in Your Covered Annual Wellness Visit?

The Medicare-covered Annual Wellness Visit is meant to be a yearly appointment with your primary care provider to create or update a personalized prevention plan.

Your Annual Wellness Visit includes a review of your medical and social history related to your health, and education and counseling about preventive services, including:

• Certain screenings, flu and pneumococcal shots, and referrals for other care, if needed;
• Height, weight, and blood pressure measurement;
• A calculation of your body mass index;
• A simple vision test;
• A review of your potential risk for depression and your level of safety;
• An offer to talk with you about creating advance directives;
• A written plan letting you know which screenings, shots, and other preventive services you need.

After completing all tests and assessments, your doctor should work with you to determine health goals. If you have any risk factors for developing new conditions, your physician will give you some options for managing those risks.

Are You Taking Advantage of Your Annual Wellness Visit?

Many Medicare recipients don’t take advantage of their covered annual wellness visit. The misconception that the Annual Wellness Visit is the same as a physical and the confusion about whether it is covered could be part of the reason why so few Medicare enrollees take advantage of the benefit. In fact, according to United Healthcare, only about 16% of beneficiaries enrolled in Original Medicare attended a wellness visit.

Another reason is that in many cases, doctor’s offices aren’t suggesting or even offering the Annual Wellness Visit to their patients. A recent study published in the journal “Health Affairs” found that in 2015 just over half of practices with eligible Medicare patients didn’t offer the Annual Wellness Visit to them. Keep in mind that if you do end up going for a full physical examination (in addition to or rather than an Annual Wellness Visit), some Medicare Advantage Plans will cover these visits. Be sure to check first!

Primary care physicians generally want to see their patients at least once a year, but it needn’t be for a complete physical exam. A wellness visit could give doctors an opportunity to check in with patients and make sure they’re on track with preventive and other care.

Be Clear When You Are Making the Appointment

“It’s very important that someone, when they call to make an appointment, asks specifically for an ‘annual wellness visit,’” according to Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”

Did You Know. . . Medicare Also Covers Advanced Directive Conversations with Doctors?

Many people are not aware of another important benefit, in addition to Annual Wellness Visits. Medicare beneficiaries may discuss options regarding end-of-life care with their health care providers at no-cost to the patient. Having these conversations can go a long way in making sure your wishes are carried out and family members aren’t left worrying about what you may or may not have wanted. These discussions typically focus on whether you want to be resuscitated, whether or not you want to go into hospice, and what, if any, treatments doctors should provide to you near the end of your life. In addition to your doctor, be sure to have a conversation about these things with your loved ones and be sure to sign an Advance Medical Directive prepared by an experienced incapacity planning attorney, such as those at the Farr Law Firm. Here are some resources to help with this important conversation.

Plan for Your Future and Your Loved Ones

If you have not signed an Advance Medical Directive or other Incapacity Planning documents such as a Power of Attorney, please contact us as soon as possible to schedule your appointment for our initial consultation:

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