Physical Exam vs. Welcome to Medicare Preventive Visit

It can be an unpleasant surprise to find out that Medicare doesn't pay for a physical exam. Most of our clients want to continue receiving a real physical exam along with preventive blood tests, like a CBC (complete blood count) panel, which can tell your doctor a lot about your health. However, Medicare does not cover these. Instead, Medicare pays for a “Welcome to Medicare Preventive Visit” during your first 12 months of enrolling in Medicare. This visit does NOT include a physical. During this visit, you and your doctor discuss the preventive services covered by Medicare and schedule the services you are due for.

Annual Wellness Visit

After that, Medicare pays for an “Annual Wellness Visit”, which is also NOT a physical. During the annual wellness visit, your doctor updates your prevention plan, and checks your height, weight and blood pressure, and updates your medication list. There are a few cognitive tests as well, but that’s about it. You do not put on a gown and your doctor does not examine you. You won’t receive preventive blood tests either.                         

What preventive services are available?

When it comes to prevention, Medicare has always provided limited coverage. Medicare does cover some preventive tests and screenings, but you must follow their frequency schedule. A few examples of preventive screenings covered by Medicare are a colonoscopy every 10 years, a once per lifetime abdominal aortic aneurysm screening, a yearly mammogram for women and an annual PSA test for men. Follow this link for the complete schedule.  

Examples of preventive services not covered by Medicare:

• Physical exams
• Preventive blood tests
• Refractive eye exams
• Hearing exams
• Shingles shots

Some Medicare Supplements will cover these preventive services not covered by Medicare. Check with your agent to see if your Medicare Supplement is one of the few that does and whether there are special instructions for getting reimbursed for these services. When shopping for Medicare Supplement insurance, be sure to find out which plans include unlimited preventive benefits, so you can continue receiving these potentially lifesaving tests and screenings. Just watch out for exclusions and limitations, because these can vary greatly from one company to the next. 

How to know the difference between diagnostic and preventive

What about diagnostic services? Medicare has always done a good job when it comes to diagnostic tests and screenings. If you have a condition that requires tests to monitor that condition, those tests would likely be considered diagnostic (not preventive) and would be covered by Medicare. An example is an INR test. My mother has an artificial heart valve. Because she takes blood thinners, she needs to have tests done periodically to make sure her blood isn’t too thick or too thin. Since the tests are related to a condition she has already has, they’re considered diagnostic lab tests and covered 100% by Medicare.

Sometimes you don't have enough qualifying symptoms

Unfortunately, it’s not always so cut and dry. What if you have symptoms, but they don’t necessarily point to one condition? Your doctor can only order tests if he or she can write down the name of the condition they are attempting to confirm or rule out, along with notes indicating a prior history, or qualifying symptoms. A real-life example can illustrate this type of situation further. A few years back, a colleague of ours named Bill, who’s in his 70’s and has Medicare and a Supplement, was having extremely low energy. He was repeatedly falling asleep in the middle of the day. He went to his doctor and asked for blood tests to try and find out what was wrong. His doctor told him that Medicare would not approve the tests, because there weren’t enough symptoms to indicate a condition. So, the doctor could not write in his notes what condition the tests would be confirming or ruling out. However, since Bill’s Supplement pays for tests denied by Medicare as preventive, Bill’s doctor ordered several thousand dollars in preventive blood tests. The results came back, and a rare blood disorder was found.

If a condition is identified, the test will qualify as diagnostic

Bill has polycythemia, which makes his body over-produce red blood cells. Having too many red blood cells makes a person’s blood thick and having thick blood can make a person very tired. Just having the blood drawn for the tests gave Bill a boost in energy levels. He said he felt as though he’d had three shots of espresso! Interestingly, the test that indicated the polycythemia was approved by Medicare as diagnostic, since a diagnosis was made. The other tests were denied by Medicare as preventive. Since Bill has unlimited preventive benefits on his Medicare supplement policy, they were covered 100%. Most supplements don’t pay for things not covered by Medicare. Had that been the case with Bill, he would have been denied the tests (most likely scenario) or been responsible for paying out of pocket.

Preventive benefits help you get tests that can save your life

Preventive tests can save your life. Because of the polycythemia, a doctor friend of Bill’s suggested he get his heart checked out with a stress test. It turns out that polycythemia alone does not qualify someone for a stress test. Bill pursued the test anyway and had a “widow-maker” heart attack while on the treadmill! His artery was almost completely blocked! Luckily, he was in the hospital and the doctors were able to put in a stent. Bill fully recovered. Thomas Burton, a Wallstreet Journal reporter, had a similar experience. He tells his story and discusses the debate over testing for debilitating strokes in the article, “The Scan That Saved My Life”. Thomas shares his reaction to the news that he had a carotid artery that was so clogged-99%, that the doctor couldn’t even detect a pulse in it. Surgery was performed to clear the artery. Because of the scan, Thomas likely avoided a debilitating, if not fatal, stroke. At the end of the article, he mentions that Lifeline Screening, a national company, can do a carotid artery screen for $70. Check the website listed below for current pricing. 

There are affordable ways to get screened 

According to Lifeline Screening, 80% of strokes are preventable. Unfortunately, most stroke victims show no prior warning signs. Without symptoms, your doctor won’t order tests, not because they don’t want to, but because Medicare (and most insurance to go with it) won’t allow them. We recommend Lifeline Screening, because Lifeline Screening is the nation’s leading mobile, vascular screening service. They provide low cost preventive tests that are recommended for people age 65 and up. Lifeline Screening is not meant to replace your doctor. When you receive your results, you can follow up with your doctor for further testing and treatment. To learn more, or to schedule a Lifeline Screening in your area, visit www.lifelinescreening.com. Some Medicare Supplement policies will reimburse for Lifeline Screenings if the policy includes unlimited preventive benefits. Be sure to ask your agent.