Does Health Insurance Cover Physicals?

December 11, 2023

Health insurance isn’t only for emergencies. It can also help you stay healthy through annual wellness visits, also known as yearly physical exams. Seeing a doctor at least once a year is the best way to prevent common diseases and make plans to combat any unique health risks you may have.

Are you curious about what preventive care is in health insurance? Read on to learn more about annual visits, coverage, and what options you may have built into your plan.

What Is a Physical Exam/Preventive Care?

A physical exam is a health assessment that assesses your overall physical health and includes treatment plans for any risks or underlying conditions you may have. According to the Cleveland Clinic, a physical exam includes examining your major organs, like your lungs and heart, as well as your nervous system, mental health, and other parts of your body.

Preventive care helps you get a headstart on treatment if you have any conditions; physical exams or wellness checks play a key role in early detection of diseases. If you need additional treatment, your doctor may refer you to a specialist.

The Affordable Care Act (ACA) requires private health insurance companies to cover certain preventive services, which includes:

  • An annual wellness visit — Your yearly physical includes a full body exam to look for signs of illness or disease and help you get any treatment you may require.
  • A mammogram — For women over 40 or those with health risks, a mammogram is a recommended annual breast cancer screening.
  • A colonoscopy — Individuals over 50 or those with health risks should have a free colonoscopy covered by insurance every 10 years.
  • Vaccinations — Flu shots and essential immunizations are considered preventive care and covered by insurance.
  • Well women visits — After age 20, annual pap smears and STD checks may be covered by insurance.

Common Health Services Not Covered by Insurance

Elective services are not usually covered by health insurance. These are treatments or appointments you choose to have but are not medically required or part of preventive care. Let’s say that you have an annual wellness visit, but you decide you want another physical later in the year. If your provider only covers one annual visit, then you would have to pay for the second one.

Unless they are deemed medically necessary, cosmetic treatments and plastic surgery are also not covered by insurance. For example, someone may benefit from a breast reduction because it causes them immense back pain, and a doctor has determined that reducing the size of their breasts would eliminate the problem.

However, someone who wants to get a breast reduction because they are unhappy with the size of their chest will have to pay for their treatment out-of-pocket.

Insurance Coverage for Physicals

The level of coverage you have for physicals depends on your policy and the type of health insurance structure you have. Coverage also varies by provider, and costs will be determined based on who provides your insurance and what your plan’s terms are.

Medicare

During the first 12 months after Part B enrollment, Medicare recipients can have a free “Welcome to Medicare” preventive visit. As long as the doctor accepts the visit, you do not have to pay for this exam. After this wellness check, Part B Medicare will cover a yearly physical. Usually, additional diagnostics tests or services you need will not be covered, so understand that lab work or treatments will likely have out-of-pocket costs or co-pays.

Medicaid

People who qualify for Medicaid do not have to pay for healthcare, including physicals. Though coverage varies greatly by state, most Medicaid recipients are free from having to pay out-of-pocket costs for preventive care, including annual physicals. Coverage is particularly comprehensive for children under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

Although adult coverage on Medicaid can vary, it generally covers preventive services and physical exams people need.

HMO Plans

Most health maintenance organization (HMO) plans cover annual physical exams. These types of plans emphasize wellness and preventive care. Once you sign up, you choose a primary care physician (PCP) who will coordinate all your care, including referrals to specialists. HMO preventive exams do not usually have a copay, but this can vary by policy.

PPO Plans

Preferred provider organization (PPO) plans offer more flexibility when it comes to preventive care, disease screenings, and general wellness visits. If your physical is performed by an in-network provider, you don’t usually have to pay a co-pay. Out-of-network provider services may also be covered at an additional cost. Most PPOs tend to offer greater free preventive care, including annual physicals.

POS Plans

A point-of-service (POS) health insurance plan combines the features of an HMO and PPO into one. Preventive care, including physicals, are a key part of their benefits package. You will need to choose a primary care physician who will refer you to other specialists as needed.

In every scenario, it’s important to speak with your insurance provider to learn more about your coverage, copays or coinsurance, and what preventive services are covered under your policy.

Find Coverage for Your Physicals Today

If you’re looking for Florida health insurance, we can help. Contact us today to speak with an experienced broker! Our dedicated team is always here to answer your questions and provide you with the most comprehensive, affordable health insurance plans, tailored to your needs.

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