Does a Medicare Supplement Cover Annual Physicals?
Get clear answers on Medicare Supplement coverage for annual health exams and preventive services.
Many individuals wonder if their Medicare benefits cover an “annual physical,” a routine check-up familiar from private insurance plans. This article clarifies how Original Medicare and Medicare Supplement (Medigap) plans interact regarding preventive services and what to expect from these plans concerning annual health assessments.
Original Medicare’s Preventive Care Coverage
Original Medicare, comprising Part A (Hospital Insurance) and Part B (Medical Insurance), covers a range of healthcare services. However, it generally does not cover a traditional, comprehensive annual physical examination, which includes a hands-on physical exam and routine blood tests without medical necessity. This often surprises beneficiaries accustomed to yearly examinations under other insurance.
Instead, Original Medicare Part B covers specific preventive visits designed to assess health risks and promote wellness.
One 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 includes a review of medical and social history, measurement of height, weight, blood pressure, and Body Mass Index (BMI), and a simple vision test. It also involves a discussion about preventive services, health screenings, and the creation of a personalized prevention plan. This visit is not a comprehensive physical exam and does not typically include routine blood tests or other diagnostic services unless medically necessary.
Following the initial period, Original Medicare covers an Annual Wellness Visit, available once every 12 months after the first year of Medicare Part B enrollment. This visit focuses on updating a personalized prevention plan, reviewing health risks, and providing health advice based on a health risk assessment. It includes routine measurements like blood pressure and weight, a cognitive assessment for signs of dementia, and a review of current medications.
The Annual Wellness Visit is not a comprehensive physical exam and does not involve a hands-on physical or routine laboratory tests unless ordered due to a specific medical concern. Both the “Welcome to Medicare” visit and the Annual Wellness Visit are generally covered at 100% by Original Medicare Part B, meaning beneficiaries typically pay no out-of-pocket costs for these specific preventive services. If additional diagnostic tests or services are performed during these visits that are not part of the covered preventive service, standard Medicare Part B deductibles and coinsurance may apply.
How Medicare Supplement Plans Work
Medicare Supplement Insurance plans, known as Medigap, are health insurance policies sold by private companies. These plans help cover some of the out-of-pocket costs associated with Original Medicare, such as deductibles, copayments, and coinsurance. Beneficiaries pay a monthly premium for their Medigap policy in addition to their Medicare Part B premium.
Medigap plans do not provide additional benefits or cover services that Original Medicare does not cover. They act as a secondary payer, covering the “gaps” in Original Medicare’s coverage once Original Medicare has approved a service. The benefits offered by Medigap plans are standardized across most states, identified by letters (e.g., Plan A, G, N). While specific plans and premiums vary by company and location, the core benefits for a plan with the same letter are identical.
Medigap policies typically cover a portion or all of the out-of-pocket expenses that remain after Original Medicare pays its share. For instance, Medicare Part B generally covers 80% of the Medicare-approved amount for most doctor’s services and outpatient care after the annual deductible is met. A Medigap plan then helps cover the remaining 20% coinsurance. This structure helps to limit unexpected healthcare costs for beneficiaries.
Medicare Supplement Coverage for Annual Physicals
Given their operational framework, Medicare Supplement plans will not cover a traditional, comprehensive annual physical exam. Medigap plans only pay for services first approved and covered by Original Medicare. Since Original Medicare generally does not cover a routine physical without medical necessity, a Medigap plan will not provide coverage.
Medicare Supplement plans will, however, cover the cost-sharing associated with the “Welcome to Medicare” Preventive Visit and the Annual Wellness Visit. Any deductibles, copayments, or coinsurance that might arise from these visits would typically be covered by the Medigap plan. For instance, some plans cover all Part B coinsurance, while others might require a small copayment.
If during a “Welcome to Medicare” or Annual Wellness Visit, a doctor determines that additional diagnostic tests or treatments are medically necessary, Original Medicare may cover a portion of these services. In such cases, the Medigap plan would then help cover the remaining out-of-pocket costs, such as the Part B deductible or coinsurance, for those medically necessary services.