Has this ever happened to you? You take advantage of Medicare’s free annual wellness visit (AWV) to your primary care provider, and shortly afterward you get hit with a hefty bill. Have you just been taken advantage of? Probably not intentionally, but you might have inadvertently crossed a blurry line that transforms an annual wellness visit into a physical exam—which Medicare doesn’t pay for.
Medicare pays in full for an AWV unless you have a medical complaint or condition that needs to be evaluated or treated; Medicare considers that portion of your visit to be a “sick visit.” You’ll be charged for the sick-visit portion of your exam, possibly along with any related tests, with the fees applied to your deductible and copay. Additionally, your provider might order expensive lab work for which you may incur more unexpected fees.
Confusion also stems from the misleading differences between the terms “routine annual physical exam” and “annual wellness visit.” The average person might think the two exams are one and the same—but they’re not. If you mistakenly request an annual physical exam instead of an annual wellness visit when you make your appointment, you’ll end up paying out of pocket separately for a comprehensive physical.
Despite the confusion, you can protect yourself from unexpected bills arising out of preventive care by learning the difference between the three main types of Medicare preventive service visits: the initial preventive physical examination (IPPE), the AWV, and the routine annual physical exam. Here’s a rundown of each:
Initial preventive physical examination
Purpose: An optional one-time “Welcome to Medicare” exam that you must undertake within the first 12 months of enrolling in Medicare Part B. Its goal is to promote good health and prevent and detect disease.
What’s covered: A limited physical exam (such as blood pressure, height, weight, and body mass index); a simple vision check; a mental health screening; and an assessment of your cognitive function, hearing, fall risk, and physical function. Your provider will also review your current medications and supplements;your and your family’s medical history; your diet; your physical activities; and any history of alcohol, tobacco, or illicit drug use. You’ll be asked if you want to discuss creating an advance directive, a legal document that expresses your health care wishes if you’re unable to speak for yourself.
After your visit, your provider will give you a personalized written prevention plan that might include referrals for preventive services such as screening mammography or a smoking cessation program.
What’s not covered: An extensive, head-to-toe physical examination; bloodwork or other clinical laboratory tests.
Who pays: Medicare pays in full for everything that’s covered.
Annual wellness visit
Purpose: A yearly health risk assessment of your physical and mental well-being, which begins after the first 12 months of Medicare Part B or Medicare Advantage eligibility.
What’s covered: A limited examination to check routine measurements (such as blood pressure and weight), your physical and mental functions as compared with your last visit, and an optional advance-planning discussion. Your provider will create or update your personalized prevention plan.
After your first AWV, subsequent AWVs may vary slightly, depending on what assessments your provider deems appropriate at the time.
What’s not covered: An extensive, head-to-toe physical examination; bloodwork and other clinical laboratory tests.
Who pays: Medicare pays if you see a provider within your Medicare provider network. While some screenings and tests your provider recommends at this visit might be covered, deductibles and copays might apply to other services. If during your AWV visit your provider identifies certain risk factors or symptoms, he or she might suggest additional tests that might not be covered. To avoid unexpected costs, ask your provider whether Medicare will cover a particular test or exam.
Avoid confusion and unexpected bills: When calling to make your AWV appointment, be clear about what service you want—and don’t use the term “annual physical” or “checkup.” Upon checking in, thoroughly read any documentation you’re asked to sign to make sure you’re not agreeing to any costs that you might not have planned for.
Routine annual physical exam
Purpose: An annual physical exam, or checkup, is a comprehensive full-body examination, which involves your doctor’s looking for any areas of concern or potential health issues. Unlike a sick visit, this examination is not one that stems from a specific complaint or issue that your doctor is trying to diagnose.
What’s covered/not covered: Nothing is covered. Your doctor may also order additional services such as blood, urine, or other tests that may or may not be covered.
Who pays: You. However, supplemental plans may help if Medicare won’t pay.
This article first appeared in the February 2020 issue of UC Berkeley Health After 50.
Also see Do You Need an Annual Checkup?