Medicare Preventive Services: The Annual Wellness Visit and Screenings With No Cost-Sharing

Three visits that are easy to confuse

People new to Medicare often book "my annual physical" and are surprised by the bill. Medicare uses three different ideas here, and only two of them are covered preventive benefits.

"Welcome to Medicare" preventive visit

Medicare.gov's page on this visit says Part B covers it once, within the first 12 months you have Part B. It includes a review of your medical and social history, information about preventive services such as screenings and vaccines, a review of your risk factors for substance use disorder, referrals for other care as needed, a body mass index (BMI) calculation, a simple vision test, a review of your risk for depression, an offer to talk about advance directives, and a written plan, like a checklist, of the screenings, vaccines and other preventive services you need. You pay nothing for the visit if the provider accepts assignment, and the Part B deductible does not apply. The page states that it is not a comprehensive physical exam.

Yearly "Wellness" visit

After that, Medicare.gov's Wellness visit page says Part B covers a Wellness visit once every 12 months. Your first one cannot take place within 12 months of your Part B enrollment or your "Welcome to Medicare" visit. The page describes it as a conversation-based visit to create or update a personalized prevention plan. You fill out a questionnaire called a Health Risk Assessment, and the provider takes routine measurements such as height, weight and blood pressure, reviews your medical and family history and your current prescriptions, performs a cognitive assessment to look for signs of dementia, reviews your risk factors for substance use disorder, offers to talk about advance directives, and gives you a written plan, like a checklist, of the screenings, vaccines and other preventive services you need. The provider may also order other tests if necessary. You pay nothing if the provider accepts assignment, and the Part B deductible does not apply.

Routine physical exam

A head-to-toe physical exam is a different service. Medicare.gov's list of what Original Medicare does not cover includes routine physical exams. If you ask for one, you may have to pay for it yourself. Some Medicare Advantage plans offer extra benefits, so if you have a plan, ask it what it covers.

Screenings and vaccines covered with no cost-sharing

Medicare.gov's preventive services page lists the services Part B covers and says you pay nothing for most of them if you get them from a provider who accepts assignment. The list includes:

• cancer screenings: mammograms, colorectal cancer screenings, cervical and vaginal cancer screenings, lung cancer screenings and prostate cancer screenings;
• heart and metabolic screenings: cardiovascular disease screenings, diabetes screenings and abdominal aortic aneurysm screenings;
• other screenings: bone mass measurements, depression screenings, glaucoma screenings, and screenings for hepatitis B, hepatitis C, HIV and sexually transmitted infections;
• counseling and programs: alcohol misuse counseling, counseling to prevent tobacco use, obesity behavioral therapy, cardiovascular behavioral therapy, medical nutrition therapy, diabetes self-management training and the Medicare Diabetes Prevention Program;
• vaccines: flu, pneumococcal, hepatitis B and COVID-19;
• HIV prevention medication: pre-exposure prophylaxis (PrEP) is a medication, not a vaccine. Medicare.gov's PrEP page says Part B covers FDA-approved oral or injectable PrEP drugs if you do not have HIV and your provider determines you are at increased risk, along with related counseling sessions and HIV screenings. You pay nothing for the drugs from a pharmacy enrolled in Part B.

Each service has its own rules on who qualifies and how often. A few common examples, as Medicare.gov describes them:

Mammograms

Medicare.gov's mammogram page says Part B covers one baseline mammogram for women aged 35 to 39 and a screening mammogram once every 12 months for women 40 and older. You pay nothing for baseline and screening mammograms if the provider accepts assignment.

Colonoscopy

Medicare.gov's colonoscopy page says Part B covers a screening colonoscopy once every 24 months if you are at high risk for colorectal cancer. If you are not at high risk, it is covered once every 120 months, or 48 months after a previous flexible sigmoidoscopy. There is no minimum age. If a Medicare-covered stool-based test or blood-based biomarker test is positive, Part B also covers a follow-up colonoscopy as a screening test.

Cholesterol tests

Part B covers cardiovascular screening blood tests for cholesterol, lipid and triglyceride levels once every 5 years, and you pay nothing if the provider accepts assignment.

Flu vaccine

Medicare.gov's flu vaccine page says Part B usually covers one flu vaccine each flu season, and you pay nothing if the provider who gives it accepts assignment. You can get it in many places, including a doctor's office or a pharmacy.

When a preventive visit turns into a bill

"No cost-sharing" applies to the preventive service itself. Several situations can still lead to a charge:

• Extra tests or services in the same visit. Both the Welcome and Wellness visit pages warn that you may have to pay coinsurance, and the Part B deductible may apply, if the provider performs additional tests or services during the same visit that Medicare does not cover under the preventive benefit. If you raise a new problem, such as knee pain, the provider may treat and bill it as a regular visit. The Wellness visit page suggests making a separate appointment for specific health concerns.
• A screening that finds something. If a polyp or other tissue is removed during a screening colonoscopy, Medicare.gov's colonoscopy page says you pay 15% of the Medicare-approved amount for the provider's services, plus a 15% coinsurance to the facility in a hospital outpatient setting or ambulatory surgical center. The Part B deductible does not apply.
• A diagnostic test instead of a screening. A mammogram done to check a symptom or a finding is diagnostic. The mammogram page says that after you meet the Part B deductible, you pay 20% of the Medicare-approved amount for diagnostic mammograms.
• A test done too often. Medicare.gov's coverage pages note that a doctor may recommend services that Medicare does not cover, or recommend them more often than Medicare covers them, which can lead to extra costs. Ask why a test is recommended and what Medicare will pay.
• A provider who does not accept assignment. The no-cost rule depends on assignment. Medicare.gov's assignment page explains how costs change when a provider does not accept it. Our assignment guide has the details.

It is reasonable to ask the office before the visit what will be billed as preventive and what will not.

Medicare Advantage plans

This guide describes Original Medicare. If you have a Medicare Advantage plan, network rules and costs are set by your plan. Ask the plan which preventive services it covers in its network, what you pay, and whether it covers a yearly physical exam as an extra benefit. Our guide to Original Medicare and Medicare Advantage explains how the two differ.

How to prepare for a Welcome or Wellness visit

What to bring

Medicare.gov's Welcome visit page suggests bringing your records, family history and medicine list; the same list works for a Wellness visit:

• your medical records, including immunization records;
• your family health history;
• a list of all prescription drugs, over-the-counter drugs, vitamins and supplements you take, how often you take them and why;
• the names of your other clinicians;
• your advance directive, if you have one;
• a list of your questions.

Questions to ask

• Is this visit being billed as my "Welcome to Medicare" visit or my yearly Wellness visit?
• Will anything today be billed separately, and what will it cost me?
• Which screenings and vaccines do you recommend for me, and how often?
• When is each one due next, and will Medicare cover it at that time?

Keep the written checklist you get at the visit. It is the easiest way to track what is due and when.

Find a clinician for your preventive care

Preventive visits are usually done by a primary care clinician. Medicare.gov's page on doctor and other health care provider services lists nurse practitioners, physician assistants and clinical nurse specialists among the providers whose services Part B covers, alongside physicians. On T-MedInfo you can browse your city from the city listings below and open the family medicine, internal medicine or nurse practitioner listings. Profiles show whether CMS's Doctors and Clinicians file lists a clinician as accepting Medicare assignment; confirm it with the office when you book. Our primary care guide covers the rest of the search, and our Part B guide explains the costs of other Part B services.