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What You Need to Know about Medicare Wellness Checkups

Copyright © 2014 AARP. All rights reserved.

When is a physical not a physical? Many people think that the Medicare annual wellness visit — a new free benefit created under the Affordable Care Act — is the same kind of comprehensive exam that patients and doctors usually call a physical. In fact, the two are quite different. So be aware that if you're a Medicare patient and ask for a physical, Medicare won't cover it, and you must pay the full cost.

During a wellness visit, the doctor measures your height, weight, body mass, and blood pressure and perhaps listens to your heart through your clothes. The rest is a discussion of your medical and family history, any physical or mental impairments, and risk factors for potential diseases such as diabetes and depression. The doctor also establishes a schedule for future care and may refer you for other tests and screenings, many of which are free under Medicare.

In other words, a wellness visit provides a snapshot of your current health as a baseline for future yearly visits and is intended as a preventive service — a way of catching potentially serious health issues early.

Until 2011, Medicare didn't cover any routine checkups except the one-time "Welcome to Medicare" preventive visit, which you can have within 12 months of enrolling in Part B. To get this initial checkup and the later once-a-year wellness visits for free (no co-pays or deductibles), you must see a doctor who accepts assignment — that is, accepts the Medicare-approved payment for this service.

Be sure to ask specifically for the wellness visit — which, in the language of Medicare billing, is coded GO438 for a first-time visit and GO439 for subsequent annual visits — to avoid being caught unawares paying for a physical.

Many physicians welcome the benefit as a paid opportunity to spend 45 minutes talking with patients to help them stay healthy. But some doctors don't offer this service at all; the law doesn't require them to. However, if necessary you can seek it from another physician or qualified provider, such as a nurse practitioner.

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