Coverage

Medicare Preventive Services: What's Covered

Medicare covers many preventive services and health screenings at the Welcome to Medicare visit, annual wellness visits and during preventive care visits. Learn about what’s covered and what costs you may face, if any.

The old saying goes that an ounce of prevention is worth a pound of cure. Change those measurements from pounds to dollars, and you see why Medicare puts so much emphasis on preventive services. As any doctor will tell you, it’s far less expensive to try to prevent illness than it is to treat it.

The Affordable Care Act (sometimes called Obamacare) took this premise even further. While some preventive services still require a copayment or coinsurance, many others are now entirely free if you meet certain guidelines and age requirements. 

Note: Typically, the following services are covered 100 percent by Medicare if your health care provider accepts assignment. Providers that accept Medicare assignment agree to accept the Medicare-approved amount as full payment for covered services. Medicare providers that do not accept assignment can charge up to 15 percent more than the Medicare-approved amount, which could mean higher out-of-pocket costs for you. Be sure to find out if your health care provider accepts assignment before getting any of the following services.

What doctor visits does Medicare cover?

There are basically three types of doctor visits that may include preventive care and can be covered by Medicare:

  • Your Welcome to Medicare visit
  • Certain preventive visits and screenings
  • Your annual wellness exam

New enrollees are often confused by the differences among these visits, because they are similar but not the same. It is always a good idea to clarify the type of visit you are scheduling before you book an appointment, so you know what services you are getting and what is or isn’t covered by Medicare.

It’s important to remember that a routine annual physical exam is not the same as your annual Medicare Wellness visit and is not a Medicare-covered service, meaning you will typically owe 100% of the amount due.

Your Welcome to Medicare visit

As the name implies, your Welcome to Medicare visit is something you schedule within the first 12 months that you have Medicare. At this visit, your doctor will go over your health and medical history, discuss your lifestyle and home welfare, and plan your future care, including preventive care. Typically, however, you do not receive preventive care at this visit – it is primarily a get-to-know-you interaction.

Your Welcome to Medicare visit may include:

  • A simple vision test
  • Height, weight and blood pressure check
  • Body mass index (BMI) check
  • Medical and social history–alcohol or tobacco use, diet, activity level
  • Depression and safety screenings
  • Discussions about creating advance directives
  • Advice and counseling on disease prevention and overall health maintenance

The Welcome to Medicare visit is free of charge to you, meaning it doesn’t require any Medicare Part B coinsurance or copays, and it doesn’t count toward your Part B deductible. It is only covered one time, and the appointment must be held within the first 12 months of enrolling in Medicare Part B.

A Medicare preventive care visit

A Medicare preventive visit is not the same as the Welcome to Medicare visit. You might visit your doctor for a standard preventive care visit to perform some of the tests and screenings that were suggested at your Welcome to Medicare visit, as needed.

A preventive visit is an opportunity to discuss your health with your doctor, including preventive services you may need.

Many screenings at a preventive visit are covered in full by Medicare, meaning you pay nothing out of pocket for the visit. But you may need some testing that does include costs such as Part B coinsurance or copayments, and you may potentially face some costs if your doctor decides you need additional treatment or diagnostic testing based on the results of your appointment.

The preventive exam doesn’t routinely cover some tests, such as lung exams and reflexes. However, if your doctor has discussed a symptom with you that requires that screening, Medicare may cover it.

A Medicare annual Wellness visit

A Medicare annual Wellness visit (AWV) is similar to a standard preventive care visit to your doctor intended to check on your health, prevent and avoid disease and create a plan to maintain wellness. But these types of visits are also different.

The yearly Wellness exam is your yearly check in, while preventive services are scheduled as needed. Once you have been enrolled in Part B for more than 12 months, you are eligible for a yearly Wellness visit.

The annual Wellness visit can include preventive services such as:

  • Health risk assessment
  • Height, weight, blood pressure and other routine measurements
  • Develop or update a list of current providers and prescriptions
  • Review of medical and family history
  • Cognitive impairment screening
  • Personal health advice
  • Your risk factors and treatment options
  • A personalized preventive services checklist

At the annual Wellness visit, you can make an appointment for any preventive care you need.

Medicare doesn’t cover routine physical exams

Medicare doesn’t cover routine physicals. You are accountable for 100% of costs for a routine physical, which can average from $50- $200 or more.

Does Medicare cover free tests and screenings?

According to Medicare.gov, the following tests and screenings can be covered by Medicare for free without out-of-pocket copays or coinsurance, depending on your situation and depending on whether your doctor accepts Medicare assignment:

  • Abdominal aortic aneurysm screening, a one-time screening for people at risk (family history of abdominal aortic aneurysms, or men between 65 and 75 who have ever smoked) who have a referral from their initial Welcome to Medicare visit or annual Wellness visit

  • Alcohol misuse screening and counseling, which can be part of your Welcome to Medicare or Annual Wellness Visit

  • Bone mass measurement, or bone density test, covered once every two years

  • Cardiovascular disease screening, covered every five years, along with one behavior therapy visit a year to talk about lowering your cardiovascular disease risk with your physician

  • Depression screening, once a year

  • Diabetes screening, up to twice a year for people at high risk of diabetes

  • Flu shots

  • Hepatitis B shots, for those at medium or high risk

  • Hepatitis C screening test, for those at high risk and with a doctor’s order

  • HIV screening, every 12 months for those under age 65. For those 65 and older, screening is only covered for high-risk individuals

  • Colorectal cancer screening, which may involve a fecal occult blood test, colonoscopy, flexible sigmoidoscopy and/or barium enema. Part B coinsurance may apply if polyps are found and removed during the screening, and if a barium enema is used during of screening

  • Lung cancer screening for current and former smokers

  • Mammogram each year, for screening only

  • Nutrition therapy services for patients with diabetes, kidney disease, or have had a recent kidney transplant

  • Obesity screening and counseling, for people with a BMI of 30 or more

  • Pap test and pelvic exam (including clinical breast exam) every two years, or more often if at high risk

  • Pneumococcal shot

  • PSA screening for prostate cancer, with no charge for an annual PSA test, but with the Medicare Part B deductible and coinsurance for a digital rectal exam

  • Sexually transmitted infection screening and counseling, including screening tests for chlamydia, syphilis, gonorrhea and hepatitis B

  • Smoking cessation counseling

Some of the following tests and screenings may require you to pay a Medicare deductible, copay or coinsurance:

  • Diabetes self-management training, for people at risk of diabetes complications. You are responsible for your part B deductible if you haven’t already met it for the year, plus 20% of the Medicare-approved amount for the training.

  • Diagnostic mammogram (a mammogram that has been ordered to diagnose an area of concern, as opposed to a routine screening test when no symptoms are present). You pay your Part B deductible if you haven’t already met it for the year, plus 20% of the cost of the Medicare cost for screening.

  • Digital rectal exam for prostate cancer. This will cost you the Part B deductible and coinsurance.

  • Glaucoma test if you are at risk. You’ll pay your part B deductible if you haven’t already met it for the year, plus 20% of the cost of the screening. A copay may also apply.

As of 2020, new Medicare beneficiaries cannot purchase a Medigap plan (also called Medicare Supplement Insurance) that covers the Part B deductible. However there are some types of Medigap plans that cover Part B coinsurance costs.

Medicare Advantage vs. Original Medicare

Medicare Advantage plans (also called Medicare Part C) are an alternative to Original Medicare that sometimes provide additional benefits.

Every Medicare Advantage plan must provide the same hospital and medical benefits as Medicare Part A and Part B, which means that the benefits listed in this article are covered by Medicare Advantage. Some Medicare Advantage plans may also cover additional preventive services that Original Medicare doesn't cover.

Some Medicare Advantage plans offer some vision and dental benefits that may include routine vision and dental checkups.

Speak with a licensed insurance agent to find Medicare Advantage plans in your area and to enroll in a plan that works for you.

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