While Medicare mainly covers the cost of diagnostic care and medical treatment, coverage sometimes also includes preventive services.
Medicare mostly covers healthcare services to diagnose and treat medical conditions. However, there are times when Medicare does cover preventive services, such as annual wellness visits.
Medicare will not usually cover other types of visits, such as an annual physical exam. This article will detail the wellness visit types that Medicare covers.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A person becomes eligible for Medicare when they turn 65 years of age.
Some people may also qualify for Medicare at an earlier age if they have:
- a disability
- end stage renal disease
- amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease)
A person is eligible for an initial physical examination within the first 12 months of Medicare enrollment. After that time, they are eligible for an annual wellness visit once every 12 months.
Medicare has different terms for physical exams and specific rules around them.
Initial Preventive Physical Examination (IPPE)
Medicare will pay for an initial medical examination. Sometimes, companies call this a “Welcome to Medicare” physical.
This exam is a one-time physical that a person must complete within 12 months of enrolling in Medicare Part B.
Some of the tests that the IPPE includes are:
- medical history reviews
- preventive services education
- social health history reviews
This medical exam is free, as long as the doctor accepts assignment. This means that they:
- accept payment directly from Medicare
- agree to receive no more payment than the Medicare preapproved amount
- agree not to bill a person for any more than the deductible and coinsurance
Annual Wellness Visit (AWV)
Medicare Part B covers yearly wellness visits, as it is the portion of Medicare that includes medical (usually nonhospital) services.
The coverage of these wellness visits comes at no extra cost, as long as the medical provider accepts assignment. The following are the types of providers who can perform an AWV:
- physician or doctor
- nurse practitioner, certified clinical nurse specialist, or physician assistant
- health educator, registered dietitian, or other health professionals whom a doctor directly supervises
Medicare will cover an AWV once every 12 months. The services that a doctor may perform include:
- setting up a personal prevention plan
- completing a health risk assessment
- updating a personalized protection plan
As long as the medical provider accepts assignment, a person does not pay for the visit, and Medicare will cover the cost.
An AWV does not include lab tests or electrocardiograms, but a doctor may perform these or other tests during the same visit.
If the doctor includes additional services in the bill that they send to Medicare, a person may have to pay any applicable copayment or deductible.
Routine physical examinations
Medicare does not cover a routine physical examination.
Plans usually provide coverage for the following:
- tests to diagnose or treat a certain illness or disease
- investigations into specific medical concerns
- treatment and examination of injuries
Medicare will often consider anything other than these types of visits to be a routine physical examination, which they will not usually cover.
The Social Security Act, which is one of the laws that govern Medicare, mentions specifically that Medicare will not cover routine physical exams. However, a person may pay for these themselves if they choose to do so.
An exception may exist for some people with Medicare Advantage, which is a Medicare plan that a private insurance company operates.
Medicare Advantage plans offer some services that Medicare may not, and in some instances, these include routine physicals.
A person can read their explanation of benefits or contact their insurance company to ensure that coverage is available for physical examinations.
There are 11 typical actions — also known as components — that make up an initial AWV. These include:
- performing health review assessments and getting a health self-assessment from the person that includes how they perform activities of daily living
- establishing medical and family history
- discussing a person’s current healthcare providers
- measuring weight, body mass index (BMI), and blood pressure
- assessing a person’s cognitive function or asking their caregiver to provide information that may help with the assessment
- looking at risk factors for depression or mood disorders
- asking about functional ability and the safety of a person’s home to help determine what fall prevention measures may be necessary
- putting a screening schedule in place, which may include when to get a colonoscopy, mammogram, bone density scan, or other screenings
- making a list of risk factors for medical conditions that may require a person to seek future medical advice
- providing health counseling and referring a person to community-based support groups, such as for nutritional advice
- helping with lifestyle changes, such as quitting smoking
Additionally, a provider may also offer advance care planning services, such as identifying caregivers in a person’s life or discussing future care decisions.
Medicare Part B also covers some other preventive services. Examples include the following:
- bone mass measurements
- depression screening
- diabetes screening
- glaucoma screening
- medical nutrition therapy
- prostate cancer screening
If a person wishes to know whether Medicare covers a particular test or service, they should contact Medicare at 800-6334-2273.
Medicare has specific rules for preventive care, including what tests the coverage includes and excludes.
When a person schedules an annual wellness visit, being specific about the type of appointment that they require may help them avoid any unwanted personal costs.
If an individual is uncertain whether their plan will cover their appointment, they should contact Medicare in advance.