Newsroom · Grand Junction

Does Medicare Cover an Annual Physical or Wellness Visit?

One of those two is a Medicare benefit. The other has been excluded by statute since 1965 — and the appointment most people book is not the one they think they're booking.

Medicare On Main Data Desk

Published August 21, 2026 · 9 min read · Reviewed by Brian Penner

Every year I have a version of the same conversation with somebody in Grand Junction who just got a bill for an appointment they were told was free. They booked "my Medicare physical." They got a Wellness visit, mentioned their shoulder, and got charged for a problem visit on top of it. Nobody did anything wrong. The two appointments have similar names, live in the same twenty minutes, and are governed by completely different rules. Here's the whole picture, and what to say when you book.

Does Medicare cover an annual physical exam?

No. The exclusion is written into the statute that created the program. Section 1862(a)(7) of the Social Security Act bars payment where the expenses "are for routine physical checkups" — sitting in the same sentence as eye exams for prescribing eyeglasses, refractions, hearing aids and immunizations. When Medicare was designed in 1965 it was insurance against the cost of getting sick, not a program that paid for staying well, and the routine checkup was deliberately left out.

What has happened since is a sixty-year series of exceptions. Congress has pulled specific preventive services out of that exclusion one at a time — screening mammography, colorectal cancer screening, bone mass measurement, the diabetes screenings, and in 2005 a "Welcome to Medicare" visit, followed in 2011 by the Annual Wellness Visit. The general physical was never among them. The AAFP's coding guidance says it in one line: a yearly physical, billed under CPT codes 99381 through 99397, is not covered by Medicare.

Sources: Social Security Act §1862(a) — Exclusions from Coverage (SSA.gov) · CMS — Medicare Wellness Visits (Medicare Learning Network) · CMS Medicare Current Beneficiary Survey — Use of Preventive Care Services · CMS: 2026 Medicare Parts A & B Premiums and Deductibles (Nov 14, 2025).

That 45% figure is worth sitting with. It means most of the benefit Congress actually did add goes unused — and the most common reason I hear is not resistance, it's confusion. People assume the free visit is the physical, discover it isn't, and quietly stop going.

The three visits people call "my physical"

There are three distinct Medicare preventive visits, plus one thing that isn't a Medicare benefit at all. Which one you're entitled to depends entirely on how long you've had Part B:

The first line is the one with a deadline on it, and it's the one that gets missed. The "Welcome to Medicare" preventive visit exists only during your first 12 months of Part B coverage. Not your first year of Medicare, not your first year of retirement — your first 12 months of Part B. There is no late version, no appeal and no exception. If you turned 65 this year and haven't used it, that is the single most time-sensitive item on your list.

The other timing rule catches people at the other end. Your first Annual Wellness Visit can't be billed within 12 months of the welcome visit, and each subsequent one requires that you haven't had a welcome visit or a Wellness visit in the previous 12 months. So a clinic that reschedules you isn't questioning your eligibility — it's protecting you from a denied claim you'd end up paying for. Before you book, ask the front desk the date of your last one.

What actually happens at a Wellness visit

This is where the expectations gap lives. A Wellness visit is a structured review of your risk and a plan for what to screen for next. It is genuinely valuable and it is genuinely not an examination:

The item I'd fight for is the written screening schedule. The visit is supposed to produce a personalized list of the preventive services you're due for over the next five to ten years — which colonoscopy interval applies to you, when the next bone density scan is, which vaccines are outstanding. Most people leave without it because nobody printed it. Ask for it before you stand up. If you want to see what the free-standing screenings actually cost once they're on that list, our piece on colonoscopy and polyp removal walks through the one where the answer changes based on what the doctor finds.

Why you got a bill for a free visit

Because you brought up your knee. That is not a joke and it is not your fault — it's the structural seam in how these visits are paid for.

The Wellness visit has its copayment and deductible waived. A medically necessary evaluation of a symptom does not. When both happen in the same appointment, the provider bills the Wellness visit and adds the problem-oriented service with modifier 25 attached, and the AAFP's guidance states the consequence directly: the E/M service is subject to a copayment. In practice that means the $283 Part B deductible if you haven't met it yet, then 20% of the Medicare-approved amount — and under Original Medicare there is no annual out-of-pocket maximum sitting behind that 20%. Labs ordered at the visit follow their own rules: some screenings are covered in full on their own schedule, and anything ordered to investigate a symptom is diagnostic and cost-shared.

None of which is a reason to stay quiet about a symptom. It is a reason to know that the moment you raise one, the appointment has changed category — and to decide deliberately whether to raise it now or book a separate visit for it. That is the entire trick, and almost nobody is told it in advance.

What the visit is looking for in Mesa County

The risk assessment isn't generic. It's aimed at the conditions that actually show up in the population around you, and Mesa County's profile is specific:

Chronic conditions among Mesa County, Colorado adults

Source: CDC PLACES, 2023 — via the Medicare On Main Data Desk. Model-based prevalence among adults, CDC PLACES county data, 2023.

High blood pressure at 26.6% and obesity at 29.8% are exactly the kind of thing a fifteen-minute risk review is built to surface — both are largely silent, both are cheap to catch and expensive to miss, and both change what else you should be screened for. The uninsured rate among working-age adults, 11.3%, matters too: a fair number of people arrive at 65 having gone years without regular care, which makes the first Wellness visit the first real inventory anyone has taken. That is an argument for using the welcome visit inside its 12-month window rather than waiting.

What changes on a Medicare Advantage plan

Two things, and one of them is a genuine advantage. Every Advantage plan must cover the Wellness visit exactly as Medicare does, with no cost sharing — that's a floor, not a plan feature. On top of it, many plans add a routine annual physical as a supplemental benefit, which Original Medicare simply does not have. If the head-to-toe exam is what you actually want, that is a real, concrete difference to compare, and it's easy to overlook because it sits in the supplemental-benefits section rather than the medical benefits chart.

The offsetting variables are the usual ones: the provider generally has to be in network, and anything the physical turns up may run into the plan's own approval process before it turns into care. If that's unfamiliar territory, prior authorization in 2026 covers what a plan can require and how quickly it has to answer. Either way, read the Evidence of Coverage rather than the mailer, and check the plans offered in Mesa County on medicare.gov/plan-compare.

How to book the visit you actually want

Four sentences, in this order, and the whole thing gets easier.

• "Am I still inside my first 12 months of Part B?" If yes, book the Welcome to Medicare visit before anything else. It expires.
• "When was my last Wellness visit?" The clinic has the date. Twelve full months have to have passed, or the claim gets denied.
• "I want the Annual Wellness Visit — not a physical." Naming it prevents the appointment from being scheduled as something Medicare won't pay for.
• "If I bring up a symptom, will that add a charge?" The answer is usually yes. Ask it before the visit, not after the statement arrives.

And bring the bottles. Every prescription, every over-the-counter drug, every supplement. The medication reconciliation is a required element of the visit and it is the part that most reliably finds something — a duplicate, an interaction, a dose nobody has revisited in four years. If your coverage question is about what those prescriptions cost rather than what the visit does, what Medicare leaves out is a decent map of the other gaps people discover the same week.

How we know all this: the Medicare On Main Data Desk frames every article with public data — here, Section 1862(a)(7) of the Social Security Act for the statutory exclusion of routine physical checkups; CMS's Medicare Wellness Visits guidance and the Noridian Medicare Administrative Contractor preventive-services pages for the frequency rules, the once-in-a-lifetime limits and the waiver of copayment and deductible; Medicare.gov's own pages on the yearly Wellness visit and the "Welcome to Medicare" preventive visit; the American Academy of Family Physicians' coding guidance for the required elements, the statement that the Wellness visit does not replace a complete head-to-toe physical exam, and the fact that a same-day problem-oriented service billed with modifier 25 is subject to a copayment; the CMS Medicare Current Beneficiary Survey for the 45% of community-dwelling beneficiaries who had a Wellness visit in 2020; CMS's 2026 Parts A & B premiums and deductibles fact sheet published November 14, 2025 for the $202.90 standard premium, the $283 deductible and the 20% coinsurance; and CDC PLACES county data (2023) for Mesa County prevalence — and qualitative language for anything an individual plan prices itself. We quote no per-visit dollar figure, because the Medicare-approved amount varies by code and setting and an Advantage plan may use a copay instead. This is education, not advice, and nothing here is medical guidance; confirm coverage and cost with your provider, your plan, or Medicare.gov. We take no payment from any carrier to feature a plan.