Medicare Coverage of a Routine Physical Examination
What It Is
Routine physical examination that's not part of a physician's attempt to diagnose a specific medical complaint, condition, or illness
In 2010, Medicare Part B doesn't cover routine physical examinations, except for one "Welcome to Medicare" examination, also called an Initial Preventive Physical Examination (IPPE), any time within 12 months of first enrolling in Medicare Part B. This exam includes a review of the patient's medical history, an electrocardiogram (EKG), and a blood pressure check, but it doesn't include laboratory testing.
Beginning January 1, 2011, though, as part of the new federal healthcare reform law, Medicare will begin covering an annual physical exam for everyone enrolled in Part B. (The annual exam isn't offered during the same year as the Welcome to Medicare physical.) This annual physical is a thorough exam that includes a comprehensive health risk assessment, which may lead to laboratory or other testing if the examining physician decides that such further testing is medically necessary. It also includes the development of a personalized prevention plan, which includes the patient's specific health risks and preventive screenings advisable for the following five years.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for a routine physical examination, contact the plan directly.
What Medicare Pays
Medicare Part B pays 100 percent of the Medicare-approved amount for the doctor's services in performing a Welcome to Medicare exam. If there are separate charges for an EKG performed outside the doctor's office, Medicare Part B pays 80 percent of the Medicare-approved amount. For annual physical examinations, Medicare has not yet determined whether it will cover 80 percent or 100 percent of the cost. However, there's no cost to the patient for the personalized prevention plan.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.