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We’ve all been there: you go in for a routine medical check-up, only to get a shockingly expensive bill in the mail a few weeks later. Aren’t preventive health screenings like that supposed to be covered? What gives?
Unfortunately, situations like this one are extremely common, and Medicare isn’t exempt from the sticker shock. It’s true that Medicare will cover preventive health services, but the definition of what qualifies as a preventive service can be unclear. In fact, you might be shocked to learn that the answer to the question ‘Does Medicare cover annual check ups?’ is actually NO.
Here’s how to understand what Medicare considers preventive, and how Medicare Advantage can help expand that definition in certain circumstances.
When we think about going to the doctor, we often think about getting an annual physical exam. Unlike a lot of medical terms, this is actually a pretty self-explanatory concept: a doctor (or other qualified health care provider) physically examines you. In addition to taking your vitals, a doctor will auscultate you (a fancy term for listening to your organs with a stethoscope), check your ears and throat, maybe check your reflexes. You might also get some blood work done. Unfortunately, if you go to your doctor and ask for a routine annual physical exam, Original Medicare (Medicare Part A and Medicare Part B) won’t cover it. At least, not under that name.
Like a vindictive genie, Medicare is very particular about terminology. It isn’t that Medicare inexplicably refuses to cover a basic doctor’s visit: there’s protocol to follow.
When you first enroll in Medicare, you’re eligible for a “Welcome to Medicare” preventive visit, which needs to explicitly be requested as such when you make your appointment. This is similar to, but not entirely like an annual physical exam. You’ll get the standard screenings as needed, but the Welcome to Medicare visit is more focused on health problems commonly found in seniors. Your vision will be tested, you’ll be screened for dementia and depression, and your doctor will discuss any preventive services you might need. You get one Welcome visit, and then that’s it: after that, your routine doctor’s appointment will be an annual Medicare wellness visit.
On the surface, a Medicare annual wellness visit isn’t dissimilar to an annual physical exam: you get your vitals checked (including your blood pressure), you discuss your medical history, all standard stuff. However, an annual wellness visit is not as comprehensive as a physical exam. Things like lab work and EKGs aren’t covered, but some other preventive services are. Here are some things to expect.
First, you’ll discuss risk factors via a health risk assessment: this is a questionnaire that helps your provider determine what other preventive services you may need. You’ll be asked about things like:
Current and past symptoms
Current medications (including OTC Medications and supplements)
Family history of illness
Details about your mental health
It’s critical that you fill this out in as much detail as possible. Even if something seems minor or inconsequential, write it down. Keep a medical journal between visits if necessary, so you don’t forget. The more detailed, the better, as your doctor may use this information to provide you with a detailed prevention plan.
After taking routine measurements, your provider will discuss this questionnaire with you, and may recommend or perform other preventive services, like diabetes screenings.
Be Aware: Medicare takes your medical history into account when recommending preventive services. For instance, biological males won’t receive bone density tests unless their provider suspects a serious risk of osteoporosis, but biological females can get tested every 24 months.
It’s important that you explicitly request a Medicare Annual Wellness Visit. If you just request a check-up, you’ll end up on the hook for the full price.
A Medicare Advantage plan may cover both Welcome to Medicare and annual wellness visits, but may also cover a more comprehensive physical exam depending on your plan. This isn’t a universal guarantee, however, so it’s important to research your options. In addition, you may need to pay coinsurance or copay depending on your plan.
If you have a qualifying condition, a Chronic Condition Special Needs Plan may offer more coverage and screenings. Otherwise, you can check what benefits different plans offer using our free comparison tool, or by calling a licensed agent at (800) 950-0608.
