If you’re a Medicare agent, you may receive calls from clients asking if Medicare covers their annual checkup. Most likely, your answer will confuse them. Many do not understand the difference between Medicare wellness visits vs checkups. Some people use these terms interchangeably. However, these are actually two different types of appointments. Understanding the distinction can help beneficiaries make the most of their Medicare benefits.
What is an annual wellness visit
An annual wellness visit is a preventive service that Medicare Part B covers. This visit helps beneficiaries and their providers create or update a personalized prevention plan based on current health and risk factors.
During this visit, the doctor reviews the beneficiary’s medical history, medications, height, weight, and blood pressure. They also assess cognitive function and risk factors for conditions like dementia. The beneficiary receives personalized health advice and screenings. The doctor and beneficiary may use this visit to discuss advance care planning and develop or update a prevention plan.
Medicare covers 100% of the cost for an annual wellness visit. In other words, there is no copay or deductible if your provider accepts Medicare assignment.
What is an annual checkup
An Annual Checkup (Routine Physical Exam) is a comprehensive medical evaluation that goes beyond the preventive focus of an annual wellness visit. Unlike the annual wellness visit, Medicare does not cover routine physicals. Those who request an annual checkup, may pay out of pocket unless they have insurance that covers it. During an annual checkup, the doctor may perform a physical exam, listen to the heart and lungs as well as order lab tests such as blood work. The provider assess overall organ function and diagnose medical issues.
Because an annual checkup involves diagnostic and treatment-related services, Medicare does not cover this visit unless it is used to address health concerns under medical necessity.
Why this matters for Medicare beneficiaries
Many Medicare beneficiaries schedule an “annual physical” expecting it to be fully covered, only to find out later that Medicare does not pay for it.
In order to avoid unexpected costs; beneficiaries who want a preventive visit covered by Medicare should ask for an “annual wellness visit.”
Click here to learn more about Medicare annual wellness visits
Anyone who needs a full physical exam including diagnostic tests, or lab work should check on the potential costs.
Understanding the difference between these visits ensures beneficiaries receive needed care and helps them avoid unexpected medical bills.
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