An annual wellness visit is essential for preventive care for many reasons. It can help you and your doctor identify potential health risks and allow your doctor time to offer crucial health advice.
In recent years, many insurance plans have started to cover the annual wellness visit at 100% without requiring a copay or coinsurance amount. So, what about Medicare coverage for a yearly wellness visit? If it is time to visit your healthcare provider for your annual checkup, you are likely wondering whether Medicare will cover it.
Keep reading as we provide all the details. We will tell you what Medicare covers and what is included in this visit.
Coverage Details For Medicare Annual Wellness Visit
So, what does Medicare cover regarding an annual wellness visit (AWV)? Your annual wellness visit will be completely covered by Medicare Part B coverage at 100%. As long as your provider accepts Medicare assignment, you will not be required to pay any deductibles, copays, or coinsurance amounts for this visit.
However, if your physician orders additional tests or medical services, you will likely owe a copay or coinsurance amount for the extra services. This could include blood tests, lab work, or other services. You might even be required to pay the total amount of these services if Medicare does not cover them.
It is also extremely important to note that an annual wellness visit is NOT an annual physical exam. Later in this article, we will dive into more detail on the differences between the two. You should know that annual physical exams are not covered at 100%. In fact, Medicare is not allowed to cover physical exams.
Medicare coverage of physical exams is prohibited by statute. Some Medicare Advantage plans might provide additional coverage for physical exams, but these plans always cover an annual wellness visit at 100% as a preventive service.
KEY TAKEAWAYS
- In most cases, your annual wellness visit will be entirely covered by Medicare Part B at 100%.
- You can receive a Medicare wellness visit free if you are a) enrolled in Medicare Part B and b) your Part B coverage has been in place for at least 12 months.
- Medicare does not cover annual physical exams. You will be required to pay entirely out-of-pocket.
Eligibility For Medicare Annual Wellness Visit
So, who can receive a Medicare wellness visit at no cost?
- You must be enrolled in Medicare Part B.
- Your Part B coverage must have been in place for at least 12 months.
Once your coverage has been in place for 12 months, then you will be eligible for your first Medicare annual wellness visit.
Remember, you cannot have received an annual wellness visit within the last 12 months. Note that you are only entitled to an AWV once every 12 months, not every calendar year. So, for example, suppose that you will receive your AWV in April 2024. You will not be eligible for another AWV until April 2025. Likewise, you cannot receive an annual wellness visit within the same year as your Welcome to Medicare visit.
The criteria listed above are the only eligibility criteria for getting your wellness visit covered. You do not need to have any specific risk factors or health conditions.
Even if you are in excellent health, you should schedule an annual wellness visit with your doctor every 12 months. This is a crucial Medicare preventive service you should not take for granted.
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What Is Included In An Annual Wellness Visit?
Many people wonder what is included in an annual wellness visit. Here is what you can expect from this visit to your doctor.
- First, your doctor will ask you to complete the Health Risk Assessment. This questionnaire asks for details about your current health conditions, medical history, social history, and family health history.
- The answers to these questions will help you and your doctor develop a personalized prevention plan to keep you healthy and lower your risk for certain diseases and conditions.
In addition to the questionnaire, you can expect some other things to happen during your visit.
- Your doctor will likely perform a detailed review of your medical and family history.
- You can also expect a review of your current medications and healthcare providers.
- Your doctor should perform some routine measurements, like your blood pressure, height, weight, and body mass index (BMI).
- Your physician will likely offer you specific health advice and a list of personalized risk factors for your situation.
- You might also receive some treatment options for any current conditions that you may have.
- Your physician will also provide a screening schedule that allows you to see when you should schedule certain preventive screenings, and you might receive a list of immunizations from which you could benefit.
Finally, a cognitive assessment is generally included in your annual wellness visit to assess cognitive function. This can be used to check for dementia or early Alzheimer’s disease. Your care team can use this to assess whether you have trouble remembering things or making decisions as part of daily living.
If your doctor believes that a more in-depth assessment is required, Medicare will cover one additional visit to perform this testing for cognitive impairment.
TIP
Medicare generally does not cover physical exams; however, Medicare beneficiaries are entitled to an initial physical examination (IPPE) during their first 12 months of Medicare coverage.
Differences Between Medicare Wellness Visit & Annual Physical Exam
So, what is the difference between your annual wellness preventive visit and an annual physical exam? We have already covered most of the details of the annual wellness visit.
Annual Wellness Visit
This visit provides some basic measurements and extensive health education. It helps to evaluate your current overall health status and identify risk factors that you should be aware of. This visit is covered 100% by Medicare.
Annual Physical Exam
An annual physical exam, on the other hand, is not covered by Medicare. You will be required to pay entirely out-of-pocket for a yearly physical.
A routine physical exam is a physical exam performed without any relationship to the treatment or diagnosis of a specific medical condition. It can be used to assess functional ability. Doctors can perform routine physical exams, but they are also commonly performed by nurse practitioners or physician assistants.
Initial Preventive Physical Examination
Even though Medicare does not cover an annual physical, Medicare beneficiaries are entitled to an initial preventive physical examination (IPPE) during their first 12 months of Medicare coverage.
Once you sign up for Medicare, you will have 12 months to schedule this visit. This Medicare preventive service encourages healthy habits and helps inform patients about risk factors and overall Medicare benefits. The Social Security Administration expressly prohibits Medicare from covering an annual physical exam.
The Bottom Line
Your Medicare annual wellness visit will be covered 100% as long as you enrolled in Medicare Part B more than 12 months ago and have not received an AWV or IPPE during the last 12 months.
No referral is required for this visit; your primary care provider will typically perform this service. Your physician will gather basic measurements and offer personalized health advice, like supplement recommendations or screening schedules.
You should bring your completed questionnaire and a list of current providers and prescriptions. Though it might not sound like a highly in-depth visit, you should not skip this essential annual preventive service.
Frequently Asked Questions
No, Medicare does not require that you receive an annual wellness visit. This is a preventive service that Medicare covers at 100%. You should use it to your benefit.
However, there is no requirement that you schedule this annual visit. Failure to schedule an annual visit does not prevent you from scheduling them in the future.
As long as you meet the eligibility requirements, your visit will still be covered even if you have never scheduled an annual wellness visit in the past.
Remember that an annual wellness visit is not the same thing as an annual physical exam.
- Blood work, lab tests, or other services are not covered as part of the yearly wellness visit.
If your doctor requests services or treatment that are beyond what is covered in the wellness visit, then you will be required to pay at least a coinsurance amount or copay for those additional services.
Yes, Medicare beneficiaries can now schedule their annual wellness visit to be performed over the phone. You might also choose to utilize telehealth services for this visit.
In addition to the annual wellness visit, you can also schedule advance care planning, smoking cessation counseling, and many behavioral health services as audio-only telephone visits.
A Medicare annual wellness visit can occur once every 12 months. Note that these visits are not necessarily tied to a calendar year.
So, if you schedule a visit in April 2024, you will not be eligible for another visit until April 2025. Just because the calendar rolls over to a new year does not mean that you will then be eligible for another wellness visit.
You can find a Social Security Administration office near you by using our SSA office locator and searching for your closest location.
