Yes, annual physicals are covered by health insurance. Physical exams are among the many preventive care benefits the Affordable Care Act (ACA) requires health plans to include. Under this mandate, private health insurance plans must cover the cost of physical exams without charging a copayment or coinsurance, even if you have not met your plan’s annual deductible.
Table of Contents
Annual Exams: a Key Part of Preventive Care
Preventive care covers services like shots and screenings, often at no cost to you. Services like routine vaccinations, flu shots, blood pressure tests, and annual physicals are included in preventive care.
Annual physicals give you and your primary care provider a chance to check in on your health. Your physical is a good time to bring up any health-related issues or concerns that may be on your mind before they become serious enough to require urgent attention. Some careers, like law enforcement, and youth and school sports, may require new hires to undergo a physical exam.
Physical exams keep a record of your health and establish a baseline for your primary care provider. Most health insurance plans cover the cost of these visits, but before you book your next annual physical, it’s important to understand the annual check-up cost with insurance.
How Do Annual Physicals Work With Insurance?
ACA Marketplace insurance plans must cover one physical per year as one of the mandated preventive care exams. These preventive services are free as long as you’re seeing a primary care provider in your plan’s network.
If you’re seeing an out-of-network provider or you need more than preventive care during your visit, you may incur out-of-pocket expenses.
If you purchased your health insurance policy before March 2010, it may be a “grandfathered” plan and not have the same requirements as ACA-approved plans. Grandfathered insurance plans may not provide the same coverage for preventative care.
Eligibility
All ACA health insurance plans, including Medicare Advantage Plans, must cover beneficiaries’ annual physicals. As long as your physical takes place with an in-network provider, it should be covered. You may be charged a fee for visiting an out-of-network provider.
Medicare Part B covers an annual wellness visit instead of an annual physical. This plan also requires you to wait 12 months after enrolling before it covers your first annual wellness visit.
Most healthcare plans cover one physical exam per year, but some require you to wait 365 days between physicals. For example, if you get a physical on March 1, you may need to wait until March 1 of the following year before your next physical becomes eligible for coverage. Contact your plan to see how it covers annual physicals.
What’s Covered in a Physical?
A physical covers an exam of your overall health. The services involved in an annual physical depend on the patient, and healthcare providers may perform different tests and exams for different patients. In general, however, you can expect the following to take place during a physical:
- Medical history review: Your healthcare provider will want to know about any history of surgeries, treatments, and diagnoses.
- Physical examination: The examination covers your physical health, including your skin, eyes, ears, nose, heart, lungs, feet, and nervous system.
- Health screenings: Healthcare providers take routine measurements of weight and height and check vital signs during an annual physical. For those assigned male at birth, providers may check their prostate and genitals. Patients assigned female at birth may have a breast exam included in their physical. Depending on the patient’s age, providers may recommend extra screenings, such as colorectal cancer screening for adults 45 to 75.
- Immunizations: Depending on your age, your provider may recommend immunizations during your physical. These immunizations include doses to cover the flu, hepatitis, measles, whooping cough, shingles, tetanus, and chickenpox.
- Lifestyle and preventive counseling: Your healthcare provider will ask about your family history and any lifestyle changes or concerns since your last physical. Issues that may require behavioral changes or counseling include tobacco and alcohol use, mental health, stress levels, sleep, and diet.
- Referrals and follow-up: If concerns come up during your physical, you may need referrals. This means your doctor may order tests or screenings with a specialist or recommend a follow-up appointment.
Limitations
Annual physicals take an overall snapshot of your health, but there are limitations. An annual exam will not include:
- Treatments for specific diseases or acute injuries, like a broken bone
- Screenings or tests that insurance plans categorize as diagnostic care, such as a diagnostic mammogram
- Emergency medical care
- Alternative therapies like massage, acupuncture, or chiropractic services
How Much Does a Physical Exam Cost?
Physical exams covered by insurance may include some fees or other costs if you go to an out-of-network provider. Extra screenings, tests, and follow-up appointments can incur charges as well.
If you do not have insurance, you can expect to pay between $50 and $200 for a physical exam. The U.S. Department of Health and Human Services provides a database of low-cost health centers to help you find affordable physical exams. Telehealth physical exams are another option and typically cost between $40 and $90 without insurance.
The Benefits of an Annual Physical
Physical exams provide a good yearly update on your health. By bringing up any health issues and concerns with your provider and answering your provider’s questions, you can protect and improve your health. Measuring vital signs and performing a physical examination may also help providers detect illnesses.
A provider’s recommended medical tests and screenings can help them catch and treat potential health concerns. Finding potential problems earlier rather than later makes it easier to treat or manage them. These screenings may also provide more details about your health, depending on your age and risk factors.
Alternatives Ways To Pay for a Physical
If you do not have insurance, options are available for covering physical exam costs.
- Community health clinics: Community health centers provide primary care without barriers like cost, lack of insurance, or distance to receive care. More than 30 million Americans use community health clinics for services like physical exams at low or no cost.
- Low-cost clinics: These clinics serve low-income and uninsured patients, along with those with limited access to care. Typically, anyone can go to a low-cost clinic to receive preventive care.
- Public health programs: Public health programs like Medicare and Medicaid offer direct services to communities across the country. If you seek preventative care through a public health program, you can receive preventative care at no cost without having to attend a specific clinic or center.
- Health savings account (HSA): Funds in a health savings account (HSA) can cover medical expenses, like the cost of a physical exam, with pre-tax dollars.
What Is the Difference Between an Annual Physical Exam and a Wellness Exam?
The terms “annual physical exam” and “wellness exam” are often used interchangeably, but these are different types of medical visits.
A physical exam measures vital signs, identifies potential health issues, and provides necessary immunizations. A wellness exam, on the other hand, helps patients make or update personalized prevention plans. During a wellness exam, the patient can explain their feelings about their health status, typically through a health risk assessment. From there, the primary care provider can create a plan that accounts for risk factors and appropriate services.
Both wellness and physical exams are covered by health insurance and federal health plans. Medicare only covers annual wellness visits, but patients must wait 12 months after signing up before scheduling a visit. If you have insurance that is not through Medicare, you will get an annual physical exam.
Putting It Together
Regardless of age, risk factors, and health status, it’s always a good idea to get an annual physical exam. Physicals are covered by insurance, so they can come at no cost to insured patients. Uninsured patients have low-cost options for their physical exams as well.
Physical exams help you and your primary care provider get a better understanding of your health status. You can use your physical exam to address any issues or concerns that may have come up since your last visit. The appointment can also help build a medical history for you over time.