Primary Care

Dear Doctor: What's The Difference Between A Regular Checkup And An Annual Wellness Visit?

DEAR DR. ROACH: I am a 69-year-old woman. I'm in good health despite various events that happened last year (i.E., a hole in my stomach lining, a loss of consciousness, a platelet-rich plasma injection in my elbow, and shoulder surgery). Also, I have asthma and a history of eosinophilic pneumonia, although it's been a number of years since I last had it.

At my 2023 physical, the physician assistant did nothing but talk to me about my medications. She didn't check my heart, lungs, or any of the common things one would expect. I was stunned, and although she has been my provider for three years, I made the decision to find a physician elsewhere.

I found a doctor at a medical hospital facility that I thought would be better, but at my 2024 physical, it was the same thing. She never got anywhere near me. We talked about my medications, then she got up and left the room.

I'm wondering if this is a new trend. I can't help thinking it's because I have Medicare. I say this because when trying to find another type of doctor, I was told that few physicians accept Medicare patients. I'm feeling down and vulnerable. If a problem comes up, I have no one to turn to other than urgent care. Please advise. -- F.D.

ANSWER: I think there's a misunderstanding here between a regular checkup (sometimes called a "physical") and an "annual wellness visit" (AWV), which is a specifically defined event approved by Medicare once yearly.

A regular checkup is a time for your regular doctor to evaluate your medical issues. Since you may be seeing specialists for your issues (most primary care doctors don't do platelet-rich plasma injections and never do shoulder surgery, while eosinophilic pneumonia generally requires subspecialist-level knowledge), your regular doctor may just be checking in with you and reading the notes from your specialists.

A physical exam that is tailored to the patient's issues is usually done, but there are times when there is so much to talk about that an exam may need to be postponed to another time. A brief discussion about prevention and screening is commonly part of a checkup to help make sure a person is up-to-date.

An AWV is not this at all. It is not intended to manage chronic conditions; instead, "the visit is an opportunity to discuss health concerns, get preventive care recommendations, and develop a plan to improve overall health and well-being." This may include a health risk assessment, advance care planning, a review of family history, an assessment for medical conditions (including falls, alcohol use and cognitive function), and some prevention like counseling, immunizations, and screening for cancer. The AWV does not include a physical exam.

I have had many patients come in for an annual wellness exam who, like you, are surprised at what the visit does and doesn't accomplish. People like that it's a no-cost visit but don't like that it isn't a complete checkup. Many doctors will do both an AWV and a checkup (also called a "problem-based visit") at the same time, but this is obviously more time-consuming and not covered by the billing for an AWV. If a physician does both, they are able to bill the patient for both, which means that the patient will have a co-pay with Medicare.

The biggest problem I see here is a lack of communication. Your doctors should have made it clear what you were and weren't getting and could have scheduled you for a problem-based visit, either at the same time or on a different day.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.Cornell.Edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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Does Medicare Cover The Well-woman Exam?

Medicare does not provide a specialized well-woman exam like the "Welcome to Medicare" wellness visit, but covered screenings and doctors' visits can include checkups for female health.

A well-woman exam typically includes screenings such as a clinical breast exam, Pap smear (Pap test), and pelvic exam, which can be conducted by your primary care doctor or a gynecologist.

Read on to learn how you can get these screenings with Medicare and others that may be beneficial if you're a female assigned at birth (FAAB)

Under Original Medicare's Part B, you can have two health and wellness checkups with a doctor: the annual wellness visit (AWV) and the "Welcome to Medicare" visit.

Medicare covers the one-time "Welcome" visit within your first year of joining Medicare. This appointment includes an in-depth review of your medical and social history. Following this visit, you can have an additional once-yearly wellness checkup with your doctor.

In addition, Part B also covers medically necessary appointments with a gynecologist if you're at risk for a gynecological condition or exhibiting female health-related symptoms that need diagnosis. This includes evaluating for conditions such as ovarian cysts, endometriosis, pelvic pain, urinary incontinence, or vaginal infections.

Part B can also cover an urgent care visit if you need to see a gynecologist immediately for acute symptoms of conditions like a UTI. But it's important to ensure you see a healthcare professional who accepts Medicare.

Screenings

At any visit with a primary doctor or gynecologist, your doctor may want to screen you for cervical and vaginal cancer. This involves a pelvic exam that may include a Pap smear, and a breast exam, which are generally covered by Medicare every 24 months. But if you are at high risk or have had an abnormal Pap test within the last 36 months, Medicare may cover these screenings annually.

Part B also provides coverage for various other tests that may be medically necessary if you're an FAAB. These include:

HPV and mammogram: Part B covers testing for the human papillomavirus (HPV) as part of a Pap test every 5 years for individuals ages 30 to 65 years who do not exhibit HPV symptoms. It also covers one annual mammogram or additional ones when medically necessary.

Bone mass measurement: You can get a bone mass test with Medicare every 2 years if you're an FAAB and your doctor determines your estrogen level is low, and you have a higher chance of developing osteoporosis.

Heart disease screenings: Two-thirds of FAABs possess one or more risk factors for coronary heart disease, and this risk grows with age. With Part B, you can get screened for heart disease once every 5 years.

It's also important to remember that if you have Medicare Advantage (Part C), you can receive the same coverage under Original Medicare. Some Part C plans may cover additional screenings that Original Medicare doesn't.

Medicare Part B fully covers the "Welcome to Medicare" visit and the annual visit without coinsurance. In addition, as long your doctor accepts Medicare, you won't pay anything for coverage.

That said, any doctors' visits and screenings beyond those that Part B covers fully will need to be determined to be medically necessary. In this case, you'll likely have to pay 20% of the cost, while Part B will cover the rest.

Remember that before Part B coverage kicks in, you have to meet your annual deductible, which in 2025 will be $257. In addition, you have to pay a monthly premium that starts at $185 a month, depending on your income.

Regarding Part C, these plans are managed by private insurers and have different premiums, deductibles, and coinsurance depending on your plan. According to the Centers for Medicare & Medicaid Services (CMS), the average monthly premium for Part C plans is around $17.00 in 2025.

In addition, to be enrolled in a Part C plan, you still have to pay the Part B premium. That said, some Part C may cover your Part B premium.

During any visit with your doctor, let them know about any concerning symptoms you currently have. You may also want to tell them about any history of physical or mental illness or allergies you or your family have, as well as your reproductive history or your experience with menopause.

Your doctor may also ask you questions about your lifestyle, including your history of smoking, your level of exercise, and your diet.

By going into these details, you can help your doctor determine what preventive screenings, vaccinations, and additional services you may need.

In addition, consider preparing a list of questions to discuss with your doctor during your visit. Questions may include:

What screening tests are suitable for my age group?

Which vaccinations should I receive?

Does my family history increase my risk for any specific health issues?

What lifestyle changes can I implement to enhance my health?

It's also common to experience anxiety before a pelvic exam. Tell your doctor if you have a history of discomfort during such procedures so they can take greater care in helping feel more comfortable.

A well-woman exam includes screenings such as a breast exam, Pap test, and pelvic exam, which are usually conducted by your primary care doctor or gynecologist.

Under Medicare Part B, you get two health check-ups: a one-time "Welcome to Medicare" visit in your first year, which reviews your medical history, and a yearly wellness visit. These visits can include such screenings.

Part B also generally covers gynecologist appointments if you're at risk for conditions like ovarian cysts, endometriosis, or vaginal infections. It can also cover urgent care for acute symptoms like a UTI. In all cases, it's important to ensure you go to a provider that accepts Medicare.

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