What is a wellness exam?
An annual wellness exam is a comprehensive preventative exam with your primary care provider for the sole purpose of preventative care. An annual exam does not include discussion of new problems or detailed review of chronic conditions. Annual exams may also be called routine check-ups, yearly exams, an annual pap, or preventive visit.
Will my insurance pay for a wellness exam?
Most health plans will pay for one wellness or preventative exam per year. Your insurance provider may consider this to be once per calendar year or one year and one day since the date of your last wellness exam. If you have had any other visit billed as preventative during this time period your plan is likely to deny your wellness exam. This would include a well-woman exam or annual pap smear. Your plan may not pay for all testing and/or labs ordered during your wellness exam. If your provider has a concern and orders diagnostic testing and/or labs during your exam you may be held financially responsible. It is the patient’s responsibility to check with their insurance provider to see what is covered under their wellness benefit and to ensure they are eligible prior to scheduling their annual wellness exam.
What is the difference between a wellness exam and a problem visit?
Preventative visits and tests ordered by your provider can help you stay healthy and catch problems early. Diagnostic visits and testing are used to diagnose a current health problem. Diagnostic tests are ordered by your provider when you have symptoms and they want to find out why. For example, your provider might want you to have a test because of your age or family history, that’s preventive care, but if it’s because you’re having symptoms of a problem, that’s diagnostic care.
Can I have a wellness exam and problem visit at the same time?
No. Billing issues prevent your provider from doing a wellness exam and a diagnostic visit on the same day. This is for your protection as your insurance carrier may deny one of these visits forwarding the financial responsibility to you. This does not prevent you from asking a simple question or requesting refills of any maintenance medications; however, we ask that you please schedule a separate appointment, on a different day, if you have any new concerns or other ongoing health problems that need more attention. Should your wellness exam turn into a diagnostic or problem-oriented visit we will bill accordingly.
Medicare- Annual preventive exam
The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit.
Medicare Part B covers the Annual Wellness Visit if:
- You have had Part B for over 12 months
- And, you have not received an AWV in the past 12 months
Additionally, you cannot receive your AWV within the same year as your Welcome to Medicare preventive visit.
During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:
- Check your height, weight, blood pressure, and other routine measurements
- Give you a health risk assessment
- This may include a questionnaire that you complete before or during the visit. The questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs.
- Review your functional ability and level of safety
- This includes screening for hearing impairments and your risk of falling.
- Your doctor must also assess your ability to perform activities of daily living (such as bathing and dressing), and your level of safety at home.
- Learn about your medical and family history
- Make a list of your current providers, durable medical equipment (DME) suppliers, and medications
- Medications include prescription medications, as well as vitamins and supplements you may take
- Create a written 5-10 year screening schedule or check-list
- Your PCP should keep in mind your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
- Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia
- Medicare does not require that doctors use a test to screen you. Instead, doctors are asked to rely on their observations and/or on reports by you and others.
- Screen for depression
- Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness
- Health education and preventive counseling may relate to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more.
AWVs after your first visit may be different. At subsequent AWVs, your doctor should:
- Check your weight and blood pressure
- Update the health risk assessment you completed
- Update your medical and family history
- Update your list of current medical providers and suppliers
- Update your written screening schedule
- Screen for cognitive issues
- Provide health advice and referrals to health education and/or preventive counseling services
If you qualify, Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.
During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.