Medicare beneficiaries are eligible for an annual wellness visit when they have had coverage for longer than 12 months. These appointments are for developing or updating a personalized plan based on individual health and risk factors to help prevent disease and disability.
It is important to note that an annual wellness visit (AWV), or wellness exam, is not the same as a routine physical exam. Some people use the terms interchangeably, but they are different types of appointments, and Medicare does not cover routine physicals.
When making this appointment with a healthcare professional, a person needs to specify it is for a Medicare AWV so it is billed and covered correctly.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare adopted AWVs in 2011 to encourage both beneficiaries and clinicians to utilize preventive services.
This AWV is an appointment with a primary care physician (PCP) to create or update a personalized prevention plan. This plan may help prevent certain illnesses or disabilities based on an individual’s overall health and risk factors.
However, it is important to remember that these visits are not head-to-toe physicals.
Anyone with Medicare is eligible for an AWV. Medicare Part B will cover the visit if a person:
- has had Part B for at least 12 months
- has not had an AWV in the past 12 months
Individuals also cannot have an AWV in the same year as their “Welcome to Medicare” preventive visit.
AWVs typically include routine measurements, health advice, a review of medical history and prescriptions, and more.
First annual wellness visit
A person’s first AWV will generally involve the following:
- completing a health risk assessment (HRA), which helps a person and their doctor develop a personalized prevention plan
- establishing a person’s medical and family history
- establishing a list of an individual’s current providers and suppliers, which are any professionals who provide medical and mental health care
- taking routine measurements, such as:
- height
- weight
- blood pressure
- body mass index (BMI)
- checking for any cognitive (thinking ability) impairments
- reviewing a person’s potential risk for depression
- reviewing an individual’s functional ability and safety
- establishing a screening schedule
- establishing a list of a person’s current risk factors and conditions
- providing personalized health advice and necessary referrals to preventive counseling services or health education programs
- completing a social determinants of health (SDOH) risk assessment
- reviewing any current opioid prescriptions and screening for substance use disorders
- providing advance care planning services if desired
Subsequent visits
Subsequent AWVs will typically involve:
- reviewing and updating an HRA and SDOH risk assessment
- updating medical and family history
- updating a person’s list of providers and suppliers
- taking routine measurements
- checking an individual’s cognitive abilities
- updating a person’s screening schedule
- updating an individual’s list of conditions and risk factors
- updating any health advice and referrals
- giving advance care planning services if desired
Medicare covers AWVs at no cost to an individual as long as their healthcare professional accepts assignment. This means they agree to accept the Medicare-approved amount as payment and not bill the person for anything more.
The Medicare Part B deductible does not apply to wellness visits.
However, a person may have to pay their deductible or coinsurance for any additional tests, services, or treatments their healthcare professional decides may be necessary based on their wellness visit.
Medicare will also only fully cover a person’s AWV if it has been more than 12 months since their Welcome to Medicare visit. An individual also cannot have more than one AWV in 12 months.
A note on Medicare Advantage
Medicare Advantage (Part C) plans must offer AWVs without charging a deductible, copayment, or coinsurance as long as a person sees an in-network provider and meets all other eligibility requirements for the service.
Routine physical exams generally entail:
- updating a person’s health history
- checking vital signs, such as blood pressure and heart rate
- performing a visual exam, where the doctor examines a person’s appearance for signs of potential conditions
- checking eyes, nose, and throat
- checking skin and nails
- testing motor function and reflexes
- performing laboratory tests, such as blood panels and urine tests
While a routine physical exam may be similar to a wellness visit, it is a separate appointment. Medicare does not cover routine physical exams.
Medicare only covers exams like this if they relate to a specific diagnosis or treatment of an illness, injury, or symptom. Otherwise, the individual is responsible for 100% of the cost.
A Welcome to Medicare visit is similar to an AWV and involves many of the same aspects.
However, this is an initial preventive visit within the first 12 months of Medicare Part B coverage.
For a Welcome to Medicare visit, a person needs to bring the following with them:
- family health history
- medical records, including immunization records
- a list of any prescription drugs, over-the-counter medications, vitamins, and supplements they are currently taking
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare covers an annual wellness visit every 12 months for beneficiaries who have been covered for more than a year.
These visits are not physical exams but preventive appointments to help create or update a personalized plan to help prevent disability and disease.