Why Did My Healthcare Provider Charge Me for a Medicare Annual Wellness Visit?

There is something very important you should know. The Social Security Act (the law that created Medicare) specifically excludes coverage for routine physical examinations. That means you are going to have to pay out of pocket for an annual physical. What does that mean for the Welcome to Medicare Visit and your Annual Medicare Wellness Visits?

What Is the Welcome to Medicare Visit?

It is more commonly known as the Welcome to Medicare Visit, but the Centers for Medicare and Medicaid Services (CMS) technically refers to it as an Initial Preventive Physical Examination (IPPE). In reality, it is a misnomer. While there is a physical exam, the requirements are limited in scope to simple vital signs (height, weight, and blood pressure) and a vision test with an eye chart.

The medical provider (a practitioner, a physician assist, a nurse practitioner, or a certified clinical nurse specialist) has the option to include "other factors deemed appropriate based on the beneficiary’s medical and social history." Without a clear consensus as to what that entails, some providers may or may not include a more extensive exam.

The Welcome to Medicare Visit is a once-in-a-lifetime event and must be completed within 12 months of enrollment in Medicare Part B. It is intended to introduce you to preventive screenings offered by Medicare and is not intended to address acute illness.

What Does the Welcome to Medicare Visit Include?

During the Welcome to Medicare Visit, your medical provider will review your medical history, including any medication conditions, past surgeries, and medications you take, both prescription and over the counter. Be sure to mention any vitamin supplements you use. Your family and social history will also be discussed, so be prepared to talk about your activity level, diet, and use of alcohol, tobacco, and/or illicit drugs.

Your healthcare provider will also perform screening to see if you are at risk for falls and will discuss end-of-life planning, including advanced directives. During this visit, you are also granted a one-time free-of-charge electrocardiogram (ECG) to check your heart.

Your medical provider will discuss the preventive services covered by Medicare and will give you a personalized checklist to help schedule tests that are appropriate for your situation. These services include but are not limited to:

• Cancer screening (e.g., colonoscopy, mammogram, Pap smear, prostate-specific antigen test)
• Depression screening (performed during the visit)
• Heart disease screening (e.g., blood pressure assessment and a laboratory test every five years to check cholesterol and triglyceride levels)
• Immunizations (e.g., influenza and pneumonia vaccines)

For people considered at high risk, screening tests may also be recommended for abdominal aortic aneurysms, diabetes, HIV, glaucoma, osteoporosis, and sexually transmitted infections. Hepatitis B vaccination is only covered for people who have diabetes, end-stage renal disease, hemophilia, past blood transfusions, or who work in health care.

Remember this visit is free of charge as long as your Medicare provider accepts assignment.

The Annual Medicare Wellness Visit

The Annual Medicare Wellness Visit is similar to the Welcome to Medicare Visit except that it does not include a vision exam or an EKG. It is also more stringent on the exam component.

The focus of this visit will be the health risk assessment (HRA). Your healthcare provider will gather information to see how well you function in your environment. This will include the evaluation of behavioral and psychosocial risk factors that place you at risk for harm as well as how well you perform activities of daily living. Home safety is key. For example, you may need to consider rubber mats in the bathtub and grab bars in the shower.

Again, you will be screened for depression. During these annual visits, you will also be screened for cognitive impairment and your preventive screening checklist will be updated.

The so-called exam is limited to vital signs (height, weight, and blood pressure) and "other routine measurements deemed appropriate based on medical and family history."

Similar to the Welcome to Medicare Visit, this visit is free of charge as long as your Medicare provider agrees to the Medicare fee schedule. You are eligible for one of these visits after 12 months of Medicare Part B coverage. It will only be covered if you have not had a Welcome to Medicare Visit or an Annual Medicare Wellness Visit within the past 12 months.

Other Medicare Office Visits

It may be the case that you have chronic medical conditions that require frequent follow-up office visits during the year. However, these evaluations are not intended to be part of your Welcome to Medicare or Annual Medicare Wellness visits. If they are performed during that scheduled time, your provider may bill you separately for that part of your care. Likewise, if you have an acute problem to address during one of these visits (for example, if you have flu-like symptoms) you will be billed for a separate visit.

It sounds counterintuitive that medical visits cannot be more efficient. Fitting more into one visit could save both time and money. Unfortunately, legislative red tape and the time it takes to complete these requirements make it difficult to do more, not to mention see all the patients that need to be seen. When your medical provider does not perform all the required elements for the Welcome to Medicare or Annual Medicare Wellness visits, Medicare may not reimburse them for the visit, even though you get it for free. That burden is one of the reasons that many doctors do not accept Medicare.

Medicare Advantage plans may also offer Welcome to Medicare Visit and Annual Medicare Wellness Visits. Some insurers may do this in the traditional office setting but others may provide house calls for these visits at no cost to you. Check your plan benefits if you are interested in a home visit.

A Word From Verywell

Medicare does not cover routine physical examinations. The Welcome to Medicare Visit and Annual Medicare Wellness Visits are focused on preventive screening and are not intended to replace routine follow-up visits or to address new health problems. Any care that is given beyond the intended scope of the visit can be billed as a separate visit.