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How No-Cost Wellness Exams Can Cost You Money out of Your Pocket

Wellness ExamIn my previous blog, I explained the difference between a “Welcome to Medicare” preventive visit and Medicare’s yearly “Wellness Visit”. Both of these exams are typically 100 percent covered by Medicare as long as your provider is a Medicare participating provider – but there are instances when these exams can lead to out-of-pocket expenses on your part. Here are a few examples:

Frequent testing or evaluation. Your doctor may order specific lab tests or procedures for you. Many lab tests and some procedures are only covered if performed during specific intervals — say every 90 days, for example. If, however, your medical condition requires a test or procedure be performed more frequently, you could be responsible for any deductible, coinsurance, and/or copayments that apply.

Routine exam turns into a not-so-routine exam. Let’s say you’re scheduled for a “preventive care” colonoscopy, an exam that is typically covered 100 percent by Medicare. If during the “preventive exam” your doctor finds a polyp or other lesion that requires removal, this “preventive care” exam is no longer “routine” and you’ll be responsible for any deductible, coinsurance, and/or copayments that apply.

Routine exam versus diagnostic exam. If your doctor schedules you for a mammogram every year as “preventive care,” this is covered 100 percent by Medicare. If, however, you see your doctor because of a lump in your breast, which requires a mammogram for evaluation, this is considered “diagnostic” and is then subject to your deductible and coinsurance.

Follow-up care and/or testing. It’s possible during your preventive care exam that your doctor may receive results that require further studies or follow-up care.  Follow-up appointments, further diagnostic testing, and referrals are not considered “preventive care,” and you will be responsible for any deductible, coinsurance or copays that apply.

An Ounce of Prevention is Worth a Pound of Cure

It’s a proven fact that prevention is the best medicine. Many illnesses can be prevented or caught early by following through with your preventive care appointments and testing — this can also help reduce your out-of-pocket costs by avoiding costly invasive procedures.

Be sure to discuss with your physician which preventive care procedures are covered and at what intervals they are covered – and always be sure you receive your results — even if you believe they are negative!

Have you been surprised by out-of-pocket charges after a preventive care visit? Share your stories —

Author: Wiley Long
Wiley Long is founder and president of Medigap Advisors, and is passionate about helping people navigate the confusing waters of Medicare. He is the author of The Medicare Playbook: Designing Your Successful Health Coverage Strategy, a clear and simple explanation so you can make the most of your Medicare coverage. For more information visit


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