Do Medicare Supplement Plans Cover Annual Physicals?

Medicare Supplement plans, often known as Medigap, are private insurance policies designed to help individuals manage certain out-of-pocket costs associated with Original Medicare. This article clarifies whether these plans cover annual physical examinations by examining Original Medicare’s foundational coverage.

Original Medicare’s Preventive Care Coverage

Original Medicare, comprising Part A (Hospital Insurance) and Part B (Medical Insurance), provides coverage for various preventive services aimed at promoting health and detecting potential issues early. Original Medicare generally does not cover a routine, comprehensive “annual physical exam” that includes blood work or other diagnostic tests unless medically necessary to treat a specific condition. Instead, it offers two distinct preventive visits.

One such benefit is the “Welcome to Medicare” preventive visit, a one-time assessment available within the first 12 months of enrolling in Medicare Part B. This visit focuses on reviewing a beneficiary’s health status, conducting routine measurements like blood pressure, height, and weight, and discussing preventive care needs. It also includes an offer to talk about advance directives and a written plan for future screenings and preventive services.

Following the “Welcome to Medicare” visit, beneficiaries are eligible for an “Annual Wellness Visit” (AWV) each year, provided 11 full months have passed since their last visit. This visit is not a traditional physical exam, but rather focuses on developing or updating a personalized prevention plan based on current health and risk factors. During an AWV, a healthcare provider will typically review medical and family history, assess health risks through a questionnaire, and establish a screening schedule for appropriate preventive services.

Medicare Supplement Plan Coverage for Approved Services

Medicare Supplement plans function by covering the out-of-pocket costs that Original Medicare beneficiaries would otherwise incur, such as deductibles, copayments, and coinsurance. These plans are sold by private companies and are standardized, meaning a Plan G from one insurer offers the same basic benefits as a Plan G from another. A fundamental principle of Medigap is that it does not add new benefits or cover services that Original Medicare does not cover. Therefore, because Original Medicare generally does not cover a routine, comprehensive “annual physical exam,” Medicare Supplement plans also will not cover these exams.

However, for preventive services that Original Medicare does cover, such as the “Welcome to Medicare” visit and the “Annual Wellness Visit,” Medicare Supplement plans can help cover any associated cost-sharing. For instance, Original Medicare typically covers these wellness visits at no cost to the beneficiary if the provider accepts Medicare assignment. If, during one of these Medicare-approved preventive visits, additional diagnostic tests or services are performed that are not part of the preventive benefit, Original Medicare’s Part B deductible may apply, along with a 20% coinsurance. In such cases, a Medicare Supplement plan would help cover these out-of-pocket costs.

Understanding Annual Physicals Versus Medicare Wellness Visits

A traditional annual physical typically involves a hands-on physical examination, blood tests, urine tests, and a detailed discussion of health concerns. This comprehensive exam assesses overall health and identifies potential problems. Original Medicare does not generally cover this routine physical exam unless symptoms warrant specific diagnostic services.

In contrast, the Medicare Annual Wellness Visit is primarily focused on health planning and risk assessment rather than a hands-on physical examination or extensive lab work. During an AWV, the healthcare provider reviews the beneficiary’s medical and family history, assesses risk factors, and develops or updates a personalized prevention plan. While routine measurements like height, weight, and blood pressure are taken, the visit usually does not include a physical examination or extensive lab tests unless medically necessary due to a specific diagnosis or symptom.

If a doctor identifies a medical necessity for further diagnostic tests or follow-up appointments during a wellness visit, those subsequent services would be covered by Original Medicare, and a Medigap plan would then help with the associated cost-sharing. These diagnostic services are considered separate from the wellness visit itself and are covered because they address a specific medical concern, not as part of a routine physical.