Annual Exams and Your Insurance: Your Questions Answered
- Category: Primary Care
- Posted On:
- Written By: St. John's Health
Understanding what’s covered during your annual exam can feel confusing, especially when insurance comes into play. To help, we’ve answered the most common questions about preventive care, annual wellness visits, and insurance coverage.
Q: What exactly is an annual exam?
An annual exam focuses on preventive care and maintaining your overall health. During this visit, your provider will:
- Perform a health review, including screenings and immunizations
- Evaluate ongoing health conditions to ensure they’re stable
Important to note:
- If ongoing conditions are stable, they’re included in your preventive insurance benefit.
- If new issues arise, or if changes to treatments or medications are necessary, these parts of the visit are billed separately.
Q: How does commercial insurance cover annual exams?
If you have commercial insurance (like BCBS, UnitedHealth, or Cigna), an annual exam usually includes:
- A hands-on physical exam
- Review of:
- Health and social history
- Lifestyle topics: nutrition, weight, mental health, tobacco, and alcohol use
- Preventive screenings for:
But here’s the catch:
If your provider addresses new illnesses, medication changes, or poorly controlled conditions, those parts of the visit will be billed separately and may not be covered under your preventive benefits.
Q: Does Medicare cover annual exams?
Not in the same way as commercial insurance. Instead, Medicare covers the Annual Wellness Visit, which focuses on:
- Health Risk Assessments
- Developing a personalized care and screening plan
- Providing health education and counseling
Good news: Medicare pays 100% for this visit, with no out-of-pocket cost to you.
What about follow-up care?
If your provider needs to address ongoing conditions or concerns after your Annual Wellness Visit, a follow-up appointment may be scheduled. These follow-ups are billed as standard office visits, meaning copays and deductibles apply.
Q: What if I have both Medicare and commercial insurance?
If you have commercial insurance as secondary to Medicare, let your provider’s office know when scheduling your appointment. You may be eligible for a traditional preventive exam similar to those offered under commercial insurance.
Note: This option isn’t available if you have a Medicare supplemental insurance plan.
Q: How can I prepare for my annual exam?
To avoid surprises, it’s always a good idea to contact your insurance provider ahead of time and ask:
- What are my deductibles and copays?
- What’s covered under my preventive benefit?
- Will additional services, like treatment for new conditions, be billed separately?
Q: What should I clarify when scheduling my appointment?
When booking, always:
- Mention your insurance type (Commercial, Medicare, or both).
- Specify the visit type:
- Preventive Annual Exam (Commercial Insurance)
- Medicare Annual Wellness Visit
This ensures you and your provider are on the same page.
Q: Why is preventive care important?
Preventive care, like annual exams and wellness visits, is essential for:
- Detecting potential health issues early
- Staying up-to-date with necessary screenings and immunizations
- Building a long-term plan to maintain your health
Taking advantage of these visits can help you stay on track for a healthier future.
Have More Questions?
If you’re unsure about your insurance benefits, here’s what you can do:
- Contact your provider’s office
- Reach out directly to your insurance carrier
Understanding your coverage ensures you can focus on what matters most: your health.
