OK – I love, love, love my Medicare… but there’s one thing that baffles me.
Now that I am rounding out my first year on Medicare, I’ve figured out that while Medicare does pay for just about everything my old, high-deductible ACA plan didn’t cover – it doesn’t appear to cover the one thing the ACA plan did pay for: an annual physical.
I’ve figured out there is something called an annual “Wellness” visit … but also that it’s not the same as a physical.
So my question is – what do we older folks do about seeing the doctor fairly regularly and getting routine lab work done? Is the workaround to simply schedule an office visit tied to some sort of medical complaint or chronic condition – and then match one’s complaints to the lab work that seems desirable to have? (example: “fatigue”)
Different terminology which makes no sense to me. Doctors and the system should have no problem understanding that the annual physical can be met by the first year “Welcome To Medicare Visit” and future year annual wellness visits to keep track of health. But some are not astute enough, apparently, to address this to their patients.
I see the confusion. But my Medicare plan pays for an annual checkup; if there’s any charge, it’s minimal. (I just looked at my portal and see no billing for this year’s annual. It’s possible I paid some coinsurance at the desk, but nothing shows.)
I did have a “wellness visit” (I was invited to see a PA) and it was a waste of time, nothing discussed that wasn’t already in my records.
Just to be clear – I am asking about standard Medicare – with billing to part B – NOT Medicare Advantage plans. (I’ve already figured that many of the Medicare Advantage plans do provide for physicals – as well as the concept that the “wellness” visit is often to see only a PA.
AARP says that the annual “wellness” visit would not typically authorize routine labs.
From this I’m thinking that these expenses might be covered by the Medigap policy … but I’m still not quite sure how it works.
The lipid panel is a good example of a test I probably should get regularly because its one of several where my test results tend to come back borderline. (Numbers are not where they should be but not bad enough to warrant medication — but probably wouldn’t be a good idea to go 5 years between tests).
The ACA didn’t and doesn’t cover a ‘physical’, it covers a ‘well person’ visit. No one has explained the difference in a sensible manner.
I did learn the hard way that if one goes to a ‘well person’ visit and mentions even ONE problem or concern it is then not fully covered under preventative care but rather as a regular style visit.
H is coming to the end of his first year on traditional Medicare with a supplemental plan. His labs are covered under regular visits he makes to get his meds ‘checked’. Sine he’s been on Medicare it surprising the number of tests that have been suggested.
Unfortunately Medicare is tricky about covering some labs. I have ongoing conditions that justify regular labs, but cannot get coverage for some other tests. (I have regular Medicare with a supplemental plan.)
For example, neither DEXA bone scans nor Vitamin D tests are covered without a specific medical need. I used to have low Vitamin D before moving from Illinois to California. Twice I needed prescriptions beyond my normal vitamins. My last test here was before I turned 65, and I was low normal. I have no symptoms suggesting a problem but I never did so who knows. One of these days I may bite the bullet and pay for the lab just to see if all the sunshine is keeping me OK. I can’t fake the required symptoms; they’re pretty specific.
That annual wellness visit seems to be keeping track of cognitive abilities, being able to care for oneself, potential balance and falling issues, and such. It’s not for general health so much as geriatric specific life issues and might be helpful for elderly living alone, or situations where no one would notice developing problems. But not really useful for “young” seniors.
@Marilyn – that brings up another question I’ve been mulling, because I also have DEXA scan and vitamin D testing questions. In my case I have a diagnosis of osteoporosis after my first (and only) DEXA scan at age 65, but I’ve opted for a program of exercise and supplements rather than medication for now. I’d like to be able to review options in a year with updated labs & scan, but Medicare is fuzzy about how often they will pay for DEXA. (Only once every 24 months, unless “medically necessary” … but what the heck does that mean?)
I know that you can’t tell me what to expect – but what really confuses me is how I can figure it out in advance. It looks like I just have to take my chances and if Medicare doesn’t pay, then file an appeal. I already know that the radiology facility that provides the DEXA scan will have me fill out a form acknowledging that Medicare might not pay-- so I’ll be on the hook.
Maybe I’m worried about nothing and my doctor knows how to properly code things so that it all gets paid for… but I’d be happier if ther was more clarity.
I just had my annual physical and whatever the doctor called it, it was fully covered by my Medicare plan. In addition, I have an incentive coupon for $25 for my “annual routine physical” which I need to have completed and mail in.
DH’s experience was the same as @thumper1. The annual physical and all labs were fully paid for. I am loving his Medicare Advantage plan! It costs zero dollars! Medicare is $430 or so every quarter. He was paying over $700/month before that, and still had to pay for a lot of stuff out of pocket. Now I go to the pharmacy and get his meds for free! He’ll also get $400 for gym membership this year.
DH did say that there are some weird rules that the doctor explained to him. Even how the physical exam is conducted. There was something about touching?? The doctor said she just ignores some of the rules because they’re silly.
@calmom I also have plain (not Advantage) medicare with the AARP supplement. Key to know about the supplement is that if medicare doesn’t pay, then neither does the supplement, which confused me for a long time.
That said, getting physicals, labs, etc … is all in the diagnostic code. I have a full physical with lipid, vit D, thyroid (not on thyroid), sugar and gobs of other things once a year and a mini-one with another set of labs in six-months. I don’t have anything wrong with me (mild allergies mostly and small high cholesterol). Medicare pays without a squeak. I had full body scan at dermatologist, paid, no problem. I had a barnacle frozen off, haven’t seen a bill.
My DH has some sever med issues and goes down to Cedars Sinai for treatment. $20,000 procedure. We got a bill!!! Called medicare and found out that maybe diagnostic code was not what the process was exactly. Called the Dr. and they resubmitted with different code. All but $700 paid. Whew.
And now he is having many many labs done. With two MRI’s so far. No bill yet.
If there are questions, grill the billing department and ask if they have a medicare specialist. And don’t hesitate to call them if you were denied and ask for a resubmit with a different code. Medicare also just changed (beginning of 2019) all the codes and some people didn’t get the memo …
@esobay – thanks for sharing your experiences, it relieves a lot of my anxiety. I can see that it’s pretty much a matter of getting things coded correctly – and good suggestion about asking to talk with a Medicare specialist in the billing department. My primary is with a very large, multi-facility group practice – so I doubt that she would have much of a personal connection with the ins and outs of billing.
Where I live, the Medicare Advantage plans are all HMO’s – and the thing I am really loving about Medicare is that I can now schedule an appointment with a specialist of my own choosing, without needing to worry about networks or copays. I just had a follow-up appointment today with an ophthalmologist… a year ago it simply wouldn’t have been possible for me to see that doctor unless I was prepared to pay out-of-pocket.
My Medicare Advantage program is technically an HMO, but functions almost entirely like a free choice plan. I do need a referral to most/all specialists, but it’s usually as simple as calling in and asking staff to get it sent. (No weird or unanticipated specialist requests.) But as my plan makes clear, the specific process and fine print can vary by region.
Interesting. In my area, most MDs won’t accept Advantage plans because they pay so low. For a session with a psychologist, the co-payment is far more than what the insurance pays.
yes, @esobay - supplementary policies (like AARP) only pick up what medicare doesn’t pay IF medicare pays on the claim. They aren’t secondary policies (which would pay as primary if Medicare didn’t pay for something).
Also wouldn’t touch an Advantage pls with a 10 foot pole. While some, like our state’ retirement plan, has a Medicare advantage plan, for the most part they are very specific and may or may not cover what you want them to. Where I live, virtually no one is accepting Medicare Advantage for a neuropsych evaluation.