Medicare beneficiaries who have had coverage for longer than 12 months are eligible for an annual wellness visit. This is designed to develop or update a personalized plan to help prevent disease and disability based on your current health and risk factors.
It is important to remember that an annual wellness visit (AWV) is not the same as a routine physical exam. Some people may use the terms interchangeably, but they are different types of appointments.
When making this appointment with your healthcare professional, be sure to specify it is for your Medicare AWV so it is billed and covered correctly.
Glossary of common Medicare terms
- Out-of-pocket cost: This is the amount you pay for care when Medicare doesn’t pay the full cost or offer coverage. It includes premiums, deductibles, coinsurance, and copayments.
- Premium: This is the monthly amount you pay for Medicare coverage.
- Deductible: This is the annual amount you must spend out of pocket before Medicare begins to cover services and treatments.
- Coinsurance: This is the percentage of treatment costs you’re responsible for paying out of pocket. With Medicare Part B, you typically pay 20%.
- Copayment: This is a fixed dollar amount you pay when receiving certain treatments or services. With Medicare, this often applies to prescription medications.
Medicare adopted AWVs in 2011 to encourage both beneficiaries and clinicians to utilize preventive services.
This AWV is an appointment with your primary care physician (PCP) to create or update your personalized prevention plan. This plan may help prevent certain illnesses or disabilities based on your overall health and risk factors.
These visits are not head-to-toe physicals.
Anyone with Medicare is eligible for an AWV. Medicare Part B will cover the visit if:
- you have had Part B for longer than 12 months
- you have not had an AWV in the past 12 months
You also cannot have an AWV in the same year as your “Welcome to Medicare” preventive visit.
AWVs typically include routine measurements, health advice, a review of your medical history and prescriptions, and more.
First annual wellness visit
Your first AWV will generally involve the following:
- completing a health risk assessment (HRA), which helps you and your doctor develop a personalized prevention plan
- establishing your medical and family history
- establishing a list of your current providers and suppliers, which are any professionals who provide medical and mental health care.
- taking routine measurements, such as:
- height
- weight
- blood pressure
- body mass index (BMI)
- checking for any cognitive (thinking ability) impairments
- reviewing your potential risk for depression
- reviewing your functional ability and safety
- establishing a screening schedule
- establishing a list of your current risk factors and conditions
- providing personalized health advice and necessary referrals to preventive counseling services or health education programs
- completing a social determinants of health (SDOH) risk assessment
- reviewing any current opioid prescriptions and screening for substance use disorders
- providing advance care planning services if desired
Subsequent visits
Subsequent AWVs will typically involve:
- reviewing and updating your HRA and SDOH risk assessment
- updating your medical and family history
- updating your list of providers and suppliers
- taking your routine measurements
- checking your cognitive abilities
- updating your screen schedule
- updating your list of conditions and risk factors
- updating any health advice and referrals
- giving advance care planning services if desired
Medicare AWVs are covered at no cost to you as long as your healthcare professional accepts assignment. This means they agree to accept the Medicare-approved amount as payment and not bill you for anything more.
The Medicare Part B deductible does not apply to wellness visits.
However, you may have to pay your deductible or coinsurance for any additional tests, services, or treatments your healthcare professional decides may be necessary based on your wellness visit.
Medicare will also only fully cover your AWV if it has been more than 12 months since your Welcome to Medicare visit. Your AWVs must also be spread out so that you do not have more than one in a 12-month period.
A note on Medicare Advantage
Medicare Advantage (Part C) plans are required to offer AWVs without charging a deductible, copayment, or coinsurance as long as you see an in-network provider and you meet all other eligibility requirements for the service.
Routine physical exams generally entail:
- an updated health history
- checking vital signs, such as blood pressure and heart rate
- a visual exam where the doctor examines your appearance for signs of potential conditions
- checking your eyes, nose, and throat
- checking your skin and nails
- testing your motor function and reflexes
- laboratory tests, such as blood panels and urine tests
While a routine physical exam may be similar to a wellness visit, it is a separate appointment. Medicare doesn’t cover routine physical exams.
The only time Medicare covers exams like this is if they are in relation to a specific diagnosis or treatment of an illness, injury, or symptom. Otherwise, you are responsible for 100% of the cost.
A Welcome to Medicare visit is similar to an AWV. This appointment entails many of the same aspects.
However, this is an initial preventive visit within the first 12 months of being covered by Medicare Part B.
For your Welcome to Medicare visit, you need to bring the following with you:
- family health history
- medical records, including immunization records
- a list of any prescription drugs, over-the-counter medications, vitamins, and supplements you are currently taking
Medicare covers an annual wellness visit every 12 months for beneficiaries who have been covered for more than a year.
These visits are not physical exams. They are preventive appointments to help create or update a personalized plan to help prevent disability and disease.