What is the difference between a physical exam and a Medicare Wellness Visit?

The difference between a physical exam and a Medicare Wellness Visit is basically the difference between your doctor focusing on what’s wrong versus on what’s right. Each is important, depending on the situation.

• When you’re sick or in pain, you want to get better. A physical exam helps your doctor figure out what the problem is and what needs to be done.

• When you’re healthy and feeling good, you want to stay that way. A wellness exam helps your doctor understand what’s working for you and how to best support your continued health and well-being.

Your doctor performs specific tasks in each of these two exams in order to achieve its purpose. See below for a chart that lists some of the services that may be covered in a physical exam versus a Medicare wellness visit, or that may be covered in both.

NOTE: this chart is not complete and you should ask your physician what is covered and your Medicare plan provider to understand how different health services may or may not be covered.

An annual physical exam is an assessment of your body’s health. The primary purpose is to look for health problems.

During the exam, your doctor uses his or her senses – mainly sight, touch and hearing – to gauge how your body is performing. Based on what’s learned, your doctor may ask you to have tests to discover or rule out possible health problems.

The list below shows some of the things your doctor may do during a physical exam.

• Visually check your body overall for signs of existing health issues

• Look into your eyes, ears, nose and throat for potential problems

• Listen to your heart and lungs to detect irregular sounds

• Touch parts of your body to feel for abnormalities

• Test your motor function and reflexes

• Perform pelvic and rectal exams

• Measure your height, weight and blood pressure

As a rule, Medicare does not cover an annual physical. The exam and any tests your doctor orders are separate services, and you may have costs related to each depending on your Medicare plan.

A Medicare Wellness Visit, also called a wellness exam, is an assessment of your overall health and well-being. The primary purpose is prevention – either to develop or update your personalized prevention plan. Medicare covers a wellness visit once every 12 months (11 full months must have passed since your last visit), and you are eligible for this benefit after you have had Part B for at least 12 months.

During the exam, your primary care provider combines information from the visit with your medical record to gauge your risk for common preventable health problems such as heart disease, cancer and type 2 diabetes. Based on what’s learned, your doctor creates your personal prevention plan with a checklist of screenings you need to have.

The list below shows some of the things your doctor may do during a wellness exam.

• Review your health risk assessment (questions you answer about your health)

• Confirm your medical and family history

• Record your current prescriptions and providers

• Measure and document your height, weight, and blood pressure

• Look for signs of memory loss, dementia, or frailty

• Document your health risk factors and treatment options

• Provide personalized health advice

• Develop a screening schedule (like a checklist) for the preventive services recommended for you

Medicare Part B covers an annual wellness exam and many preventive screenings with no copay or deductible. However, you may have to pay a share of the cost for certain recommended tests or services. And while it’s not mandatory, there are very good  reasons to have a wellness exam every year.

Medicare Part B covers a "Welcome to Medicare" visit. This visit is also called an Initial Preventive Physical Exam (IPPE). You are eligible for this benefit once within the first 12 months you are enrolled in Part B

During the visit your provider will:

• Record and evaluate your medical and family history, current health conditions and prescriptions.

• Check your blood pressure, vision, weight and height to get a baseline for your care.

• Make sure you are up-to-date with preventive screenings and services, such as cancer screenings and shots.

• Order further tests, depending on your general health and medical history.

You do not pay a copayment for your "Welcome to Medicare" visit. The Part B deductible does not apply to the cost of the visit either.

After the visit, your provider will give you a personalized prevention plan or checklist with the screenings and preventive services recommended for you. These services are not part of the "Welcome to Medicare" visit. You may have to pay a co-payment for the recommended services when you get them. Your Part B deductible may also apply.

Learn more about what to expect at your Medicare wellness visit.