Aging Options

Expecting Medicare to Pay for Your Annual Physical Exam? Think Again!

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Imagine this scenario. You call the office of your new primary care physician and schedule your annual checkup, assuming Medicare will cover the cost. The appointment goes well and the exam seems thorough.  Then to your surprise, a few days after the appointment you get a bill for $400. Assuming it’s a billing mistake, you call the doctor’s office, only to find out that you’re wrong, and you’re on the hook for the bill. That’s because – surprise – Medicare does not cover the cost of an annual physical.

Annual Physical and Annual Wellness Visit: Not the Same

The example cited above actually happened to a 69-year-old Texas woman, and if that story perplexes you, we felt the same way. That’s why we’re encouraging our AgingOptions blog readers to check out this article we just discovered on the Kaiser Health News website. According to the article, many Medicare beneficiaries make the same mistake she made, assuming annual physicals are covered by traditional Medicare, only to find out that what seems like a minor discrepancy in wording can trigger a big medical bill. “Federal law prohibits the health care program from paying for annual physicals,” warns Kaiser, “and patients who get them may be on the hook for the entire amount. But beneficiaries pay nothing for an ‘annual wellness visit,’ which the program covers in full as a preventive service.”

The article includes this link to a 15-page document produced for physicians by CMS – the Centers for Medicare and Medicaid Services – explaining the difference. “It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’” said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging, quoted in the Kaiser article. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”

Annual Physical is More Comprehensive and Thorough

According to Kaiser Health News, an annual wellness visit is not simply an annual physical by another name. Instead, the AWV as CMS calls it is less comprehensive. “An annual physical typically involves an exam by a doctor along with bloodwork or other tests,” the article explains. “The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure.”  That’s because the purpose of the Medicare wellness visit “is on preventing disease and disability by coming up with a ‘personalized prevention plan’ for future medical issues based on the beneficiary’s health and risk factors.”  Typically, when a patient comes in for their first wellness visit, they’ll complete a questionnaire and review family and personal health history with medical staff. “The clinician will typically create a schedule for the next decade of mammograms, colonoscopies and other screenings and evaluate people for cognitive problems and depression as well as their risk of falls and other safety issues,” Kaiser says, and they may also discuss planning for advance care directives. Then during future visits, “the doctor and patient will review these issues and check basic measurements. Beneficiaries can also receive other covered preventive services such as flu shots at those visits without charge.”

As described in this information sheet from the Center for Medicare Advocacy, the idea of an Annual Wellness Visit is a recent one, mandated under the Affordable Care Act in January, 2011. But coverage of annual physical examinations has always been excluded under Medicare rules going back more than 50 years. The difference can be subtle. “If a wellness visit veers beyond the bounds of the specific covered preventive services into diagnosis or treatment — whether at the urging of the doctor or the patient — Medicare beneficiaries will typically owe a copay or other charges,” says Kaiser. In other words, if a visit goes beyond prevention, the patient may get hit with a bill. To further add to the confusion, some Medicare Advantage plans do offer coverage of full annual physical exams, so you’ll want to check your terms of coverage carefully before making that appointment.

Few Are Actually Receiving an Annual Wellness Visit

In spite of the fact that the annual wellness visit is supposed to be offered to all Medicare beneficiaries, Kaiser makes it sound like that’s just not happening. One study cited by Kaiser said that in 2015 fewer than 20 percent of those covered by Medicare received an AWV, and about half of all health care practices accepting Medicare didn’t even offer these appointments to their patients. What’s more, while the Kaiser article did not refer to the issue, present court challenges to the Affordable Care Act make us wonder whether the mandate to offer annual wellness visits might be in jeopardy. We’ll watch this issue as the case proceeds.

Planning for your health needs in retirement is a critical need. We at AgingOptions have generally urged that aging men and women are better served by entrusting their health care to a geriatrician, not merely a family practice doctor. The difference is significant, because a geriatrician is thoroughly trained in the unique health care needs of older adults. These professionals will take the time to listen and to evaluate carefully, and you’ll feel like an individual, not a number. We urge you to say good-bye to cookie-cutter medicine and instead to call AgingOptions this week and let us provide you with a list of geriatricians in your area.

If you’re getting serious about planning for your retirement future, we hope you’ll accept the invitation from Rajiv Nagaich of AgingOptions to join him soon at a free event called a LifePlanning Seminar. Rajiv will show you an exciting model for comprehensive retirement planning in which health care, financial security, legal protection, housing choices and family communication are all woven together into one powerful and seamless blueprint. Come discover how to build the retirement of your dreams!  You’ll find a calendar of upcoming seminars on our Live Events page – then simply register for the date and time that works for you.

There’s no “hidden secret” to proper retirement planning – it’s available to you today from the professionals at AgingOptions. Age on!

(originally reported at

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