Know Your Benefits: Differentiating Wellness Visits from Physical Exams in Medicare Part B


Maintaining good health is a journey that requires regular check-ins and assessments, especially under Medicare Part B. Two commonly confused terms are the “Wellness Visit” and the “Routine Physical Exam.” Though they may sound similar, they serve different purposes in promoting overall well-being. This article will explore the distinctions between these two essential components of preventive health care under Medicare Part B.

Yearly Wellness Visit

If you’ve had Medicare Part B (Medical Insurance) for over 12 months, you’re eligible for a yearly “Wellness” visit. This visit helps develop or update a personalized plan to prevent disease or disability based on your current health and risk factors. Note that the yearly “Wellness” visit is not a physical exam.

Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.


Risk Assessment

During a Wellness Visit, your health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop or update a personalized prevention plan to help you stay healthy and get the most out of your visit.

Your visit may include:

  • Routine measurements (like height, weight, and blood pressure)
  • A review of your medical and family history
  • A review of your current prescriptions
  • Personalized health advice
  • Advance care planning
  • A screening schedule (like a checklist) for appropriate preventive services
  • An optional “Social Determinants of Health Risk Assessment” to help your provider understand your social needs and their impact on your treatment

Your health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.


Your Costs in Original Medicare

If your doctor or healthcare provider accepts assignment, you won’t have to pay anything for this visit, and the Part B deductible doesn’t apply. However, you might still need to pay coinsurance.

Routine Physical

Under Medicare Part B, routine physical exams are not typically covered. The exam and any tests your doctor orders are separate services, and you may have costs related to each depending on your Medicare plan.

An annual physical exam is an assessment of your body’s health, and primary purpose serves to look for health problems.

During your exam, your healthcare provider may:

  • Visually check your body overall for signs of existing health issues
  • Look into your eyes, ears, nose, and throat for potential problems
  • Listen to your heart and lungs to detect irregular sounds
  • Touch parts of your body to feel for abnormalities
  • Test your motor function and reflexes
  • Perform pelvic and rectal exams
  • Measure your height, weight, and blood pressure

Ultimately, the choice between a wellness visit and an routine physical depends on your individual health needs and coverage. It’s important to discuss with your healthcare provider to determine which option aligns best with your health goals and ensures a comprehensive approach to your well-being

Key Takeaways

Make sure you know what is covered under your Medicare plan and what the differences are. While both aim to maintain and improve health, the wellness visit is more about prevention and planning, whereas a routine physical is a thorough physical evaluation.

Navigating the world of Medicare can be a challenge. Contact your M3 Elevate team today to help guide you with precautionary measures to avoid penalties and ensure proper coverage.

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