What Medicare Actually Pays For
Under Original Medicare there are exactly three covered "checkup" style visits, each with its own code and frequency rule.
Welcome to Medicare Visit (G0402). A one-time visit available only during your first 12 months of Part B. This one does include a limited physical component: height, weight, body mass index, blood pressure, vision screening, and a depression risk review. Cost to you: $0.
Initial Annual Wellness Visit (G0438). Your first wellness visit, available once you have had Part B for more than 12 months. It cannot be billed in the same year as the Welcome to Medicare visit. Cost to you: $0.
Subsequent Annual Wellness Visit (G0439). Every year after that, once per 12 months. Cost to you: $0.
Medicare reimburses providers approximately $174 for an initial AWV and $138 for a subsequent one under the 2026 physician fee schedule. That payment goes to the practice. Nothing passes through to you, because Part B waives the deductible and coinsurance entirely for these codes.
New in 2026: the Physical Activity and Nutrition Assessment
Effective January 1, 2026, Medicare began paying for a standardized 5 to 15 minute assessment of your physical activity level and nutrition habits, reimbursed at approximately $20 to $25.
The cost-sharing rule here has a trap. Performed during your Annual Wellness Visit and billed on the same claim with modifier 33, the deductible and coinsurance are waived and you pay nothing. Performed during a regular problem-focused office visit, it is billable up to every six months but your normal Part B deductible and 20% coinsurance apply. Same service, same code, different bill, decided entirely by which visit it was attached to.
What Medicare Does Not Pay For
The routine comprehensive preventive medicine codes, CPT 99381 through 99397, are statutorily excluded from Medicare coverage. These are the codes commercial insurers use for the annual physical most people had before turning 65. Medicare has never covered them and there is no appeal path, because the denial is not a medical-necessity judgment. It is a coverage exclusion written into the law.
Also excluded from the wellness visit itself:
- Blood panels, lipid panels, and metabolic panels ordered as routine screening rather than under a specific covered screening benefit
- Urinalysis
- Chest X-rays and EKGs done as routine screening (the EKG is covered once, as a referral from the Welcome to Medicare visit)
- Examination of specific body systems, including heart, lungs, abdomen, ears, and reflexes
- Diagnosis, treatment, or medication management for any condition you already have
Some lab work people associate with a physical is covered separately under Medicare's individual preventive benefits. Cardiovascular blood screening is covered once every five years, and diabetes screening up to twice a year for beneficiaries with certain risk factors. Those are separate benefits with separate rules, and your provider has to order each one on its own.
Why the Surprise Bill Happens
Almost every unexpected bill after a wellness visit traces back to one of four situations.
1. The appointment was booked as a physical. You called and said "I need my annual physical." The scheduler entered a preventive medicine code. Medicare denied it. You now owe the practice's full charge, commonly $150 to $500 depending on the market and the complexity billed.
2. You brought up a medical problem and the doctor worked it up. This is by far the most common. You went in for the free wellness visit, then mentioned your knee has been hurting or asked about a change to your blood pressure medication. Once the provider evaluates that issue, they can bill a separate office visit code with modifier 25 attached, meaning a significant and separately identifiable service was performed on the same day. The wellness portion stays free. The problem portion runs through your medical benefit, subject to the 2026 Part B deductible of $283 and then 20% coinsurance.
3. The visit was billed as a physical plus a wellness visit. Some practices offer a "Medicare annual physical" that bundles the covered AWV with the non-covered physical exam elements, bills Medicare for the G-code, and bills you directly for the difference. This is legal if you were given an Advance Beneficiary Notice of Noncoverage first. If nobody handed you an ABN and had you sign it before the visit, Medicare's limitation of liability rules generally shift the cost to the provider, and they cannot collect from you.
4. The frequency clock had not reset. Medicare pays for one AWV per 12 months. If your last one was 11 months ago, the claim gets denied for frequency and the practice may bill you. Eligibility resets on the first day of the same calendar month the following year, so a visit on April 20, 2025 makes you eligible again on April 1, 2026.
The Cost Math on a Split Visit
| Scenario | What Medicare pays | What you owe in 2026 |
|---|
| AWV only, provider accepts assignment | 100% | $0 |
| AWV plus separate problem visit, deductible not yet met | AWV in full, $0 on the office visit | Up to $283 toward the deductible, then 20% |
| AWV plus separate problem visit, deductible already met | AWV in full, 80% of the office visit | 20% coinsurance, typically $15 to $50 |
| Routine physical billed as 99397 | $0 | Full charge, typically $150 to $500 |
| AWV with physical activity and nutrition assessment, modifier 33 | 100% of both | $0 |
How to Schedule So You Do Not Get Billed
Step 1: Use the exact words. Call your provider's office and say "I want to schedule my Medicare Annual Wellness Visit." Do not say physical, checkup, or annual exam. If the scheduler asks whether you want a physical too, say no unless you are prepared to pay for it.
Step 2: Confirm the provider accepts Medicare assignment. Providers who accept assignment take Medicare's approved amount as payment in full. Non-participating providers can charge up to 15% above the Medicare rate, and that excess is yours. Check the physician lookup on Medicare.gov or call 1-800-MEDICARE.
Step 3: Confirm your 12-month clock. Ask the office to verify your last AWV date through the Medicare eligibility system before you come in. It takes seconds. If you are within your first 12 months of Part B, you want the Welcome to Medicare visit instead.
Step 4: Save your medical questions for a separate appointment. If you have a sore shoulder, a new medication concern, or a chronic condition that needs adjusting, book a second visit for it. That appointment will cost you the deductible and coinsurance, but it will not turn your free visit into a billed one.
Step 5: Refuse to sign an ABN you do not understand. If the front desk hands you an Advance Beneficiary Notice at check-in, read the estimated charge and the reason listed. Signing it means you have agreed to pay if Medicare denies. You can decline the non-covered portion and still receive the covered wellness visit.
Step 6: Ask what will be billed before you leave. A simple question at checkout, "is anything today being billed outside the wellness visit," resolves most disputes before a claim is filed.
What to Do If You Already Got a Bill
Do not pay it immediately. Work through these steps first.
- Request an itemized statement listing every code billed for that date of service. You are entitled to it.
- Pull your Medicare Summary Notice, mailed quarterly or available anytime at MyMedicare.gov. Compare the codes on the MSN to the itemized bill.
- Look for modifier 25. If a problem-focused office visit was billed alongside the AWV, ask the practice to document what separately identifiable service was performed. The modifier by itself does not prove medical necessity.
- Check whether you signed an ABN. No signed ABN before a non-covered service generally means the provider absorbs the cost.
- Ask the practice to rebill if a covered wellness visit was coded as a non-covered physical. Coding corrections are routine and do not require an appeal.
- File an appeal if the denial stands and you believe the service was covered. You have 120 days from the date on your Medicare Summary Notice to file a redetermination.
- Call your State Health Insurance Assistance Program (SHIP) for free one-on-one help. Every state has one, and the counseling is free.
Medicare Advantage Works Differently
Medicare Advantage plans must cover the Annual Wellness Visit with no cost sharing, matching Original Medicare. Where they differ is on the physical.
Many Medicare Advantage plans include a routine annual physical as a supplemental benefit that Original Medicare does not offer, sometimes at $0 and sometimes with a copay. Plans also frequently offer in-home health assessments, which are not the same thing as the AWV.
Check your Evidence of Coverage document under preventive services before assuming either way. The rules are set by the plan, not by Medicare, and two plans from the same carrier in the same county can differ.
If You Want a Physical Anyway
Some people want the hands-on exam and are willing to pay. In 2026 a self-pay annual physical typically runs $150 to $500 at a primary care office, with a national median around $250. Retail clinics and urgent care run lower, roughly $75 to $200. Lab work is billed on top, usually another $30 to $200 depending on the panels.
Two ways to reduce that: ask for the practice's self-pay or time-of-service rate before the visit, which commonly cuts 10% to 30% off the charge, and schedule the physical in a different month than your wellness visit so the claims do not collide and trigger a denial on the covered visit.
If Medicare premiums and out-of-pocket costs are straining your budget, the four Medicare Savings Programs (QMB, SLMB, QI, and QDWI) can cover your Part B premium of $202.90 per month in 2026, and the QMB program also covers deductibles and coinsurance. These are administered by your state Medicaid agency, and a large share of eligible beneficiaries never apply.
Frequently Asked Questions
Does Medicare cover an annual physical exam?
No. Medicare does not cover a routine annual physical exam at any point, at any age. The comprehensive preventive medicine codes (CPT 99381 through 99397) are excluded by statute. What Medicare covers instead is the Annual Wellness Visit, a preventive planning appointment billed under HCPCS G0438 or G0439, at $0 to you.
What is the difference between a Medicare wellness visit and a physical?
The wellness visit is an assessment and planning appointment. Your provider reviews your history and medications, screens your cognition and mood, takes basic measurements, and writes you a personalized prevention schedule. A physical is a hands-on examination of your body systems, usually with lab work, aimed at finding and treating problems. Medicare pays for the first in full and does not pay for the second.
How much does a Medicare wellness visit cost in 2026?
Nothing, if your provider accepts Medicare assignment. There is no deductible, copayment, or coinsurance for the Annual Wellness Visit. The $283 Part B deductible for 2026 does not apply to it.
Why did I get a bill for my free Medicare wellness visit?
Usually because a second, billable service was performed at the same appointment. If you raised a medical concern and the provider evaluated or treated it, they can bill a separate office visit code with modifier 25, and that portion is subject to your deductible and 20% coinsurance. The other common cause is the visit being booked and coded as a routine physical, which Medicare denies outright.
Can my doctor bill both a wellness visit and an office visit on the same day?
Yes, if the office visit addresses a problem that is significant and separately identifiable from the wellness visit. The provider appends modifier 25 to the office visit code. This is legitimate billing, not a mistake, but you owe the cost sharing on the office visit portion. If you want to avoid it, keep medical concerns out of the wellness appointment.
Does the Medicare wellness visit include blood work?
No. Lab work is not part of the Annual Wellness Visit. Your provider may order screening labs separately under Medicare's individual preventive benefits, such as cardiovascular blood screening every five years or diabetes screening for at-risk beneficiaries. Anything outside those benefits falls under your regular Part B coverage.
Do Medicare Advantage plans cover an annual physical?
Many do, as a supplemental benefit beyond what Original Medicare offers. Coverage and copays vary by plan and by county. Check your plan's Evidence of Coverage under preventive services, and note that a plan's in-home health assessment is a separate service that does not replace the Annual Wellness Visit.
What is an ABN and do I have to sign one?
An Advance Beneficiary Notice of Noncoverage is a form telling you a service may not be covered and estimating what you would owe. You are not required to sign it, and you can decline the non-covered service and still receive the covered wellness visit. If a provider bills you for a non-covered service without having you sign an ABN beforehand, they generally cannot collect from you.
How often can I get an Annual Wellness Visit?
Once every 12 months. Eligibility resets on the first day of the same calendar month in the following year, so a visit on September 22, 2025 makes you eligible again on September 1, 2026. Claims submitted early are denied for frequency, and the practice may bill you.
