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Routine question about Medicare (for old timers)

calmomcalmom 20522 replies167 threadsRegistered User Senior Member
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")
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Replies to: Routine question about Medicare (for old timers)

  • cptofthehousecptofthehouse 29210 replies57 threadsRegistered User Senior Member
    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.
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  • lookingforwardlookingforward 33430 replies363 threadsRegistered User Senior Member
    edited September 10
    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.
    edited September 10
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  • calmomcalmom 20522 replies167 threadsRegistered User Senior Member
    edited September 10
    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.

    Example:
    For example, our previously mentioned analysis shows that almost a third of people going for an AWV got a blood test to measure their cholesterol (lipid panel) on the same day. Such blood tests are not part of the AWV. For most people, Medicare covers screening lipid panels only once every five years. Beneficiaries who get the test with any more frequency during their AWV incur a coinsurance and deductible.
    From https://blog.aarp.org/thinking-policy/medicares-annual-wellness-visit-what-to-expect

    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).



    edited September 10
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  • dietz199dietz199 3586 replies73 threadsRegistered User Senior Member
    edited September 11
    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.
    edited September 11
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  • lookingforwardlookingforward 33430 replies363 threadsRegistered User Senior Member
    Yes, I do have an MA plan. Can only speak to that. And that the wellness visit was well done but a waste of time.

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  • MarilynMarilyn 3693 replies124 threadsRegistered User Senior Member
    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.
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  • calmomcalmom 20522 replies167 threadsRegistered User Senior Member
    @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.
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  • thumper1thumper1 74205 replies3245 threadsRegistered User Senior Member
    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.

    $0 deductible, fully covered.
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  • MaineLonghornMaineLonghorn 38084 replies2086 threadsSuper Moderator Super Moderator
    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.
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  • thumper1thumper1 74205 replies3245 threadsRegistered User Senior Member
    @MaineLonghorn my gym memberships are at no cost at Silver Sneakers eligible gyms!

    I’ve had both regular Medicare, and Medicare Advantage, and both fully covered my annual physical...whatever the doctor called it.
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  • MaineLonghornMaineLonghorn 38084 replies2086 threadsSuper Moderator Super Moderator
    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.
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  • FlyMeToTheMoonFlyMeToTheMoon 2975 replies45 threadsRegistered User Senior Member
    Not only does our Medicare Advantage plan pay for the annual physical, but we receive a $25 gift card just for going! Love it!
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  • esobayesobay 1328 replies19 threadsRegistered User Senior Member
    @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 .....
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  • jym626jym626 55304 replies2877 threadsRegistered User Senior Member
    edited September 11
    I haven’t had to activate Medicare B as I am still on DH’s insurance, but both my PCP and my OB said the Medicare “wellness check” is limited in what they cover and doesnt cover several of the things (don't recall what) that they would order/do. https://www.communitycare.com/News/Health-Blog-Article?URLName=Medicare-Annual-Wellness-Visit-vs-an-Annual-Physical
    edited September 11
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  • calmomcalmom 20522 replies167 threadsRegistered User Senior Member
    @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.
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  • lookingforwardlookingforward 33430 replies363 threadsRegistered User Senior Member
    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.
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  • bookwormbookworm 8861 replies72 threadsRegistered User Senior Member
    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.
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  • jym626jym626 55304 replies2877 threadsRegistered User Senior Member
    edited September 12
    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.
    edited September 12
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  • lookingforwardlookingforward 33430 replies363 threadsRegistered User Senior Member
    See, it depends on where you live. Maybe I shouldn't move, after all.

    Basic differences between a M supplement and an M Advantage plan.
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  • calmomcalmom 20522 replies167 threadsRegistered User Senior Member
    A lot of my friends in my area have Medicare Advantage plans via Kaiser and are very happy with them -- but generally, they were already on Kaiser, so for them, it was just a way to continue with a plan they were happy with.

    Other than that, it's not so much whether a provider takes Medicare Advantage, but rather which plan they take. Because it's the same basic network problem that is part of all the ACA plans -- the companies save costs by negotiating directly with the providers and then limiting patient choice to those providers.

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