Did You Know? Medicare Does Not Cover A Physical Exam

A friend, new to Medicare, asked me whether Medicare covered annual physicals. I told him, “No, it doesn’t.” The Social Security act clearly prohibits Medicare from paying for annual physical examinations.

A week later, he told me I was wrong. He found proof that Medicare does indeed cover these examinations. “Physical exams, right there, on the HHS.gov website, in the list of services that Part B covers.” (Health and Human Services is an agency of the federal government that administers health and welfare programs, including Medicare.)

I replied that I wasn’t wrong, HHS just shortened the title for a preventive service that Medicare does cover.

The Affordable Care Act introduced the Initial Preventive Physical Examination. This preventive service for those with Medicare does not resemble a physical exam. There is no palpation (feeling with fingers or hands), no auscultation (listening to body sounds) and no percussion (tapping body parts), all essential components of a physical examination. And, unlike annual physicals, you only get one visit, within the first 12 months of Part B enrollment.

Because “physical examination” is in the regulatory title, there was and still is considerable confusion. Medicare now calls this service a “Welcome to Medicare” preventive visit.

More about the Welcome Visit

The Welcome to Medicare visit is a review of your medical and social history and counseling about preventive services. Specifically, this visit includes:

• Height, weight, and blood pressure measurements
• A calculation of body mass index
• A simple vision test
• A review of risk factors for depression, functional ability and safety level, and current opioid prescriptions
• Screening for visual acuity and potential substance use disorders
• Education, counseling, and referral based on previous components, and
• End-of-life planning (if the patient consents).

Annual Medicare Wellness Visit

Medicare offers a second preventive visit; this one is every 12 months. It may be annual, but this visit is also not a physical exam. The purpose is to update the personalized prevention plan. The components include:

• A review of medical and family history
• Height, weight, blood pressure, and other routine measurements
• Detection of any cognitive impairment
• Personalized health advice
• Updating the list of current providers, suppliers, prescriptions, and health risk factors, and
• Advance care planning.

Both these visits address a plan for screenings, vaccinations, and other preventive services, including:

• Flu and COVID vaccinations
• The RSV (respiratory syncytial virus) vaccine (now covered with no cost sharing under Part D, prescription drug coverage)
• Annual mammogram
• Prostate cancer screening, and
• Colonoscopy.

Medicare covers many more preventive services designed to help beneficiaries stay healthy, most with no cost sharing. Find the list here.

Take-away points

First, here are a few points about the two wellness visits.

• There is no cost for the initial welcome or annual wellness visits.
• However, if the physician addresses a medical issue, such as elevated blood pressure, don’t be surprised if you get a bill. That’s because the visit would be considered diagnostic and cost sharing (deductible and/or copayment) applies.
• If you have Original Medicare, see providers who accept Medicare assignment.
• If you chose a Medicare Advantage plan, schedule your appointments with in-network physicians, most likely with your primary physician.

And here’s what my friend and you need to know about annual physical exams.

• Even though Medicare does not cover them, you can still get a physical exam. But know that you may have to pay for parts or all of it. For example, Part B would cover an EKG or chest x-ray for medical reasons, like an abnormal heart rhythm or severe lung congestion, with the usual cost sharing.
• Some Medicare Advantage plans offer routine physical exams, generally when performed by the primary care physician. Check the plan’s Evidence of Coverage for more information.
• Finally, no matter the issue, know that what you read on a website may not be correct. Double check coverage before you proceed.