You’ve had Medicare coverage for the past year, and your first annual wellness visit is coming up. This is your opportunity to review your health history with your doctor and ask questions about how to maintain your well-being.

However, an annual wellness visit isn’t a physical exam. Before your appointment, it’s essential to understand what Medicare covers and what your yearly visit entails. That way, you’ll attend your annual wellness visit with your questions prepared and schedule the necessary appointments for other health needs.

What is covered in a Medicare annual wellness visit?

Medicare covers an optional Social Determinants of Health Risk Assessment and preventive health information from your doctor. The visit is intended to help you maintain your health and reduce your risk of developing health conditions, especially those that run in your family and your own medical history.

During your annual wellness visit, you and your doctor will review your health and social history.¹ You’ll talk about potential health risks based on history and how you can reduce them. For example, suppose you have a sedentary lifestyle and a family history of type 2 diabetes. In that case, your doctor can recommend ways to incorporate movement into your day and reduce your risk of disease.²

During the first part of the appointment, you’ll fill out a health risk assessment. Your provider will also do other screenings based on the US Preventive Services Task Force (USPSTF), including those for:³

• Depression
• Hypertension
• Tobacco use
• Dementia
• Cancer
• Diabetes

Your doctor will use their electronic health maintenance tool to check if you’re due for any immunizations and review your current medications. If you need other preventive services or referrals, your doctor may offer those during this appointment.

Your provider may offer to talk about advance care planning with you. If you’re unable to make medical decisions for yourself in the future, this plan will help decide how you want to be treated or designate someone you trust to do it for you.

Medicare Part B covers you receiving personalized preventive care information, including a written plan from your doctor that details preventive health advice. Your appointment may include an assessment to determine if you need additional preventive services after your annual wellness visit.

Your provider will also let you know if you’re due for any vaccines. However, you might not receive them at this visit.

What is not covered in a Medicare annual wellness visit?

The Medicare annual wellness visit is not a physical exam. Confusing the two can result in you having to cover the entire cost of your appointment out of pocket instead of getting full coverage through Medicare Part B.

During your annual wellness visit, your doctor will check your height, weight, and blood pressure. However, they may not assess other vital signs or perform a regular physical examination.

If you’re considering saving a recent health concern to discuss at your annual wellness visit, consider scheduling an appointment sooner. Your doctor won’t be able to check your recent injury, ongoing soreness, or symptoms of new chronic conditions during your annual wellness visit. They will also not assess or discuss new health concerns during this appointment if they aren’t present in your health history.

If you book an office visit before your annual, you’ll be more likely to have the information you need to ask your doctor about additions to your history. While your doctor may review your current medications, they will not adjust or change them during the annual wellness visit. This appointment does not:

• Assess your current or active symptoms
• Diagnose new conditions or illnesses
• Address health concerns that haven’t come up in previous visits

By addressing these issues during your annual office visit, your provider will have this information in their electronic health system in advance. This allows you both to prepare before the visit, so you can ask the appropriate questions and get actionable answers.

The annual wellness visit covers certain screenings as included in the USPSTF. However, it doesn’t include lab tests, such as routine blood work, or many other screenings, including those for certain autoimmune conditions.

Your annual wellness visit is a focused conversation about your health history and preventive care that applies to your health needs. It is intended to provide you with a plan to move forward, utilizing additional tools and gaining a deeper understanding of how to maintain your optimal health.

What is covered in a physical exam but not a Medicare annual wellness visit?

It’s easy to confuse the Medicare annual wellness visit with a physical exam. However, any kind of exam beyond discussing your health history may change the billing for this appointment into an office visit.

Here are a few things that are not covered with your annual wellness visit (even if they’ve been covered at your previous physical exams):

• Blood tests or X-rays
• Physical examinations
• Examination of symptoms
• Diagnosis of a new medical condition or progression of a current one
• Treatment for acute illnesses
• Review, adjustment, or change of medications
• Vaccinations and immunizations
• Other diagnostic tests

Even though Medicare Part B doesn’t cover these as part of the annual wellness exam, many of them are still covered as part of a different kind of visit. For example, if you book an office visit to discuss your recent headaches, Medicare will cover up to 80% of the appointment cost.

Check your Medicare benefits before scheduling a visit, so you can ask for the right kind of appointment. That way, you don’t have to pay out of pocket for services that could have been covered.

How do you know what type of appointment to make?

During your annual wellness visit, it is essential to prioritize discussing preventive care with your doctor. Prepare to discuss your health and social history, and how it will factor into your self-care going forward.

If you need health advice beyond that, an exam or treatment for your current symptoms, or adjustments to a medication, you’ll need to schedule an office visit.

With an office visit, your doctor can look at acute or chronic health issues without rushing through your health history. By focusing on your health history during your annual visit, you ensure you have time to ask in-depth questions and understand your doctor’s advice.

Meanwhile, during an office visit, you can:

• Get new health concerns examined
• Adjust or change medications
• Talk about managing current health conditions
• Assess concerns about chronic illnesses
• Get any necessary vaccines
• Run diagnostic tests, like lab tests and X-rays

Your annual wellness visit is a good time to ask for referrals to specialists, too. For example, if you screen for depression and need mental health services, you can get a referral for a therapist or psychiatrist.

You’ll need to make these specialist appointments separately. Medicare covers many providers and specialists; however, it’s a good idea to check your coverage before scheduling an appointment. Some services are only covered for exceptions.

Making the right kind of appointment outside of your annual wellness visit makes it easier to accommodate health changes into the conversation about your medical history. Additionally, your providers can collaborate to ensure you receive the most accurate advice for maintaining your health.

Why should you still go to your annual wellness visit?

A sick visit to the doctor might get you the treatment you need for a single issue, but it doesn’t help you maintain your overall health. You don’t have much time for discussing other concerns outside of the most pressing current issue.

Your annual wellness visit provides an opportunity to discuss with your doctor how to maintain optimal health. By using this appointment to talk through your health history, you can bring up concerns before they become urgent. For example, if type 2 diabetes runs in your family, your doctor may offer guidance on maintaining healthy habits that reduce your risk of developing it.

You may not know about all the risk factors for developing a disease or condition. For example, smoking tobacco can put you at a higher risk of developing a heart or lung condition.⁴ Your doctor can review these risk factors with you during your annual wellness visit. Then, you’ll have a better idea of how to manage your health and lower those risks.

Along with staying on top of your health, your annual visit lets you build a relationship with your doctor. It builds trust between you both and makes asking hard questions more comfortable. Medicare annual wellness visits last longer than the typical office visit. You have time for a conversation, not just a diagnosis.

Preparing for your appointment by completing available questionnaires beforehand can give you more time to discuss your health. Review your health and social history yourself, list your medications, and consider your health goals before your visit, too. Then, your provider can tailor their advice to you and make the most of your Medicare annual wellness visit.

References

• (1) Medicare.gov. (n.d.) Yearly “Wellness” visits. https://www.medicare.gov/coverage/yearly-wellness-visits
• (2) Hamilton, Marc T, Deborah G Hamilton, Theodore W Zderic. “Sedentary behavior as a mediator of type 2 diabetes.” Med Sport Sci. (2015, September 9). https://pmc.ncbi.nlm.nih.gov/articles/PMC4364419/#:~:text=Consistent%20with%20the%20logical%20proposition,was%20key%20for%20insulin%20sensitivity.
• (3) U.S. Preventive Services Task Force. (n.d.) A & B Recommendations. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• (4) National Heart, Lung, and Blood Institute. (2022, March 24). How Smoking Affects the Heart and Blood Vessels. https://www.nhlbi.nih.gov/health/heart/smoking#:~:text=Smoking%20is%20a%20major%20risk,plaque%20buildup%20in%20the%20arteries.