Medicare wellness visits vs. a physical: what's free and what isn't

Three visits that sound alike

Many people on Medicare book a "yearly checkup" and are surprised by a bill afterward. Often the reason is that Medicare treats three kinds of visits very differently:

• The "Welcome to Medicare" preventive visit, a one-time visit when you're new to Part B.
• The yearly "Wellness" visit, often called the Annual Wellness Visit, available once every 12 months after that.
• A routine physical exam, which Original Medicare does not cover.

The "Welcome to Medicare" visit

You can get this visit once, within the first 12 months you have Medicare Part B. Medicare describes it as a review of your health and of the preventive services you may need. It is not a comprehensive physical exam.

According to Medicare.gov, the visit includes:

• A review of your medical and social history.
• A calculation of your body mass index (BMI).
• A simple vision test.
• A review of your potential risk for depression.
• An offer to talk about advance directives, such as a living will or naming someone to make health decisions for you.
• A written plan letting you know which screenings, shots and other preventive services you need.

The yearly Annual Wellness Visit

After your first year with Part B, Medicare covers a yearly "Wellness" visit once every 12 months. Your first one can't take place within 12 months of your Part B enrollment. You don't need to have had the "Welcome to Medicare" visit to qualify.

The focus is planning to keep you well. Medicare says your provider will ask you to fill out a questionnaire called a Health Risk Assessment, and the visit can include:

• Routine measurements, like height, weight and blood pressure.
• A review of your medical and family history.
• A review of the prescriptions you take now.
• A cognitive assessment to look for signs of dementia, including Alzheimer's disease.
• An offer to talk about creating advance directives.
• A written plan, like a checklist, showing which screenings and vaccines you need.

What it costs

For both the "Welcome to Medicare" visit and the yearly Wellness visit, you pay nothing if your provider accepts assignment. Accepting assignment means the provider agrees to take Medicare's approved amount as full payment. The Part B deductible doesn't apply to these visits.

That $0 covers the visit itself. It doesn't automatically cover everything that happens in the room.

Why you might still get a bill

Medicare says that if your provider performs additional tests or services during the same visit, you may owe coinsurance, and the Part B deductible may apply. If Medicare doesn't cover the additional tests or services at all, such as a routine physical exam, you may have to pay the full amount.

In practice, this often happens when the visit turns to a new problem or an ongoing condition. If you ask about a new pain or want a medicine adjusted, your provider may bill that part as a separate, regular office visit.

What about a physical?

A routine physical is a hands-on head-to-toe exam, often with routine lab work. Medicare.gov says plainly that the yearly Wellness visit isn't a routine physical exam, and it lists a routine physical as an example of a service Medicare may not cover, which can leave you paying the full cost.

Some Medicare Advantage Plans offer extra benefits beyond Original Medicare. If you're in one, check your plan's Evidence of Coverage or call the plan to ask whether a yearly physical is included and what it costs.

How to prepare

A little preparation helps you get the most from a short visit:

• When you book, say you want your "Medicare Annual Wellness Visit" (or "Welcome to Medicare" visit), not a physical.
• Ask whether the provider accepts Medicare assignment.
• Bring a list of every medicine, vitamin and supplement you take, with doses.
• Bring a list of your other doctors and any recent test results.
• Write down your family health history and any falls, memory concerns or mood changes.
• Bring your vaccine records, if you have them.
• If you want to discuss a new problem, ask whether it will be billed separately or should be a separate visit.

After the visit

Keep the written plan you're given. It's your checklist for the coming years. Many of the screenings and shots on it are also Medicare preventive services. Medicare says you pay nothing for most preventive services if you get them from a provider who accepts assignment. Examples include screening mammograms, colonoscopies, diabetes screenings, lung and prostate cancer screenings and flu shots.

Some screenings have their own rules on how often they're covered and who qualifies. Before you schedule one, ask your provider or call Medicare to confirm it's covered for you. You can also log in to your Medicare account to see which preventive services you're due for.

Bottom line

The wellness visits are a free chance to review your health, plan your screenings and talk about your wishes for future care. Use them, but know what they are and aren't. This article is general information. Talk with your doctor about your own health, and call 1-800-MEDICARE (1-800-633-4227) or your plan if you have questions about coverage.