While Medicare mainly covers the cost of diagnostic care and medical treatment, coverage sometimes includes preventive services as well.
Medicare primarily covers healthcare services used to diagnose and treat medical conditions.
At times, Medicare also covers preventive services, such as annual wellness visits. However, it does not usually cover other types of visits, like annual physical exams.
This article details the types of wellness visits that Medicare does cover.
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 is eligible for one initial preventive physical examination (IPPE), also known as a Welcome to Medicare physical exam, within the first 12 months of enrolling in Medicare Part B.
Medicare enrollment typically begins when a person turns 65 years old. People may qualify at an earlier age if they have specific disabilities or health conditions, according to the Centers for Medicare & Medicaid Services (CMS).
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 healthcare professional performing the exam accepts the assignment. This means that they:
- accept payment directly from Medicare
- agree to receive no more compensation than the Medicare preapproved amount
- agree not to bill a person for any more than the deductible and coinsurance
Medicare Part B also covers annual wellness visits (AWV) at no extra cost, providing the medical professional accepts the assignment.
According to CMS, the following are the types of healthcare professionals 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 covers 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
Medicare Part B also covers some other preventive services, per CMS. Examples include:
- bone mass measurements
- colorectal cancer screening
- depression screening
- diabetes screening
- glaucoma screening
- medical nutrition therapy
- prostate cancer screening
- breast cancer screening
An AWV does not include lab tests or electrocardiograms, but a healthcare professional may perform these or other tests during the same visit. If the doctor includes additional services in the bill they send to Medicare, an individual may have to pay any applicable payments, copayment, or deductible.
If a person wishes to know whether Medicare covers a particular test or service, they should contact Medicare at 800-633-4227 or go to Medicare.gov.
Medicare has specific rules for preventive care, including what tests the coverage includes and excludes.
Medicare covers one IPPE within someone’s first year of Part B coverage. Medicare also covers one AWV each year.
When a person schedules an AWV, they should specify the type of appointment that they require. This may help them avoid any unwanted personal costs.
If an individual does not know whether their plan will cover their appointment, they should contact Medicare in advance.