Medicare’s Physical Exam Isn’t Really A Physical Exam At All

A friend, new to Medicare, asked me whether Medicare covered annual physicals. I told him, “No, it doesn’t.”  

A week later, he told me I was wrong. He found proof that Medicare does indeed cover these examinations. “Physical exams, right there, on the HHS.gov website, in the list of services that Part B covers.” (Health and Human Services is an agency of the federal government that administers health and welfare programs, including Medicare.) 

“I wasn’t wrong,” I replied. HHS is, or maybe it just shortened a title.

Federal statute clearly prohibits Medicare from paying for annual physical examinations. However, the Affordable Care Act introduced Medicare’s version, called the Initial Preventive Physical Examination. This preventive service does not even resemble a physical exam. There is no palpation (feeling with fingers or hands), no auscultation (listening to body sounds) and no percussion (tapping body parts), all essential components of a physical examination. And, unlike annual physicals, you get only one visit, within the first 12 months of Part B enrollment. 

Because “physical examination” is in the regulatory title, there was and still is considerable confusion. I suspect Medicare has tried to ease that by now calling this service a “Welcome to Medicare” preventive visit. (I could not find any mention of the Initial Preventive Physical Examination on medicare.gov.) 

More about this Welcome Visit

The Welcome to Medicare visit includes a review of your medical and social history and counseling about preventive services. Specifically, the components include:

• Height, weight, and blood pressure measurements
• A calculation of body mass index (BMI)
• A simple vision test
• A review of risk factors for depression, functional ability and safety level, and current opioid prescriptions
• Screening for visual acuity and potential substance use disorders 
• Education, counseling, and referral based on previous components 
• A written plan addressing screenings, vaccinations, and other preventive services, and
• End-of-life planning (if the patient consents). 

Annual Medicare Wellness Visit

Medicare offers a second preventive visit; this one occurs every 12 months. It may be annual, but this visit also does not constitute a physical exam. Its purpose is to update the personalized prevention plan. This visit includes:

• A review of medical and family history
• Height, weight, blood pressure, and other routine measurements
• Detection of any cognitive impairment
• Personalized health advice
• Updating the list of current providers, suppliers, prescriptions, and health risk factors, and the schedule for appropriate preventive services, and 
• Advance care planning.

What my friend and you need to know 

• There is no cost for these two wellness services. 
• However, if the physician addresses a medical issue, such as your blood pressure is elevated, the visit could be considered diagnostic and Part B costs could apply. 
• If you have Original Medicare, see providers who accept Medicare assignment.
• If you have a Medicare Advantage plan, schedule your appointments with in-network physicians, most likely with your primary physician. 
• You can still get a physical exam, but you may have to pay for parts or all of it. For example, Part B would cover an EKG or chest x-ray for medical reasons, like an abnormal heart rhythm or severe lung congestion, with the usual cost sharing. But if you want a body scan, as advertised on TV, you’ll pay for that because it’s not medically necessary. 
• Some Medicare Advantage plans offer routine physical exams, generally when performed by the primary care physician. Check the plan’s Evidence of Coverage for more information. 
• Know that what you read on a website may not always be correct. Double check your coverage and costs before you proceed.