Does Insurance Cover Your Annual Physical?

What does the law say about preventive care coverage?

Under the Affordable Care Act (ACA), most non-grandfathered health plans must cover a defined set of preventive services without any cost-sharing — zero copay, zero deductible — when you use an in-network provider 1Ref 1U.S. Department of Health and Human Services (2024).Preventive Care | HHS.gov.ACA requirement that non-grandfathered health plans cover USPSTF A/B-rated preventive services and annual wellness visits at zero cost-sharing when in-network. The annual preventive wellness visit is included in this mandate.

This requirement applies to employer-sponsored plans, individual marketplace plans, and most other private plans. Plans that existed before the ACA and have not changed significantly ("grandfathered plans") are not required to meet this standard 1Ref 1U.S. Department of Health and Human Services (2024).Preventive Care | HHS.gov.ACA requirement that non-grandfathered health plans cover USPSTF A/B-rated preventive services and annual wellness visits at zero cost-sharing when in-network.

Medicare Part B covers an Annual Wellness Visit (AWV) and, for new enrollees, a "Welcome to Medicare" preventive visit. Medicaid coverage of preventive visits varies by state but is generally strong. The preventive care mandate has faced legal challenges over the years; confirm your current benefits with your insurer.

Why might I receive a bill after a 'free' physical?

This surprises many patients. If, during your annual physical, you bring up a specific symptom — a rash, knee pain, a recurring headache — or your doctor finds something unexpected and addresses it, the visit can be split into two charges 2Ref 2American Academy of Family Physicians (2022).Combining a Wellness Visit With a Problem-Oriented Visit: A Coding Guide.Permitted use of Modifier 25 to bill a separate E&M service (CPT 99202–99215) during the same visit as a preventive medicine service; documentation requirements and patient communication best practices:

1. The preventive portion, covered at 100%. 2. A separate office-visit charge for the problem discussion, subject to your normal copay or deductible.

This split billing uses a separate CPT code (in the 99202–99215 E&M range) appended with Modifier 25, which signals to the insurer that a distinct problem-oriented service occurred during the same visit as the preventive exam 2Ref 2American Academy of Family Physicians (2022).Combining a Wellness Visit With a Problem-Oriented Visit: A Coding Guide.Permitted use of Modifier 25 to bill a separate E&M service (CPT 99202–99215) during the same visit as a preventive medicine service; documentation requirements and patient communication best practices. This is a permitted billing practice under AMA and CMS guidelines, not a billing error — though actual errors do occur and are worth checking.

To reduce the chance of a split bill, you can schedule a separate appointment for specific concerns, or ask your doctor upfront: "Will addressing this change how today's visit is coded?"

Are labs and screenings at my physical covered?

Many screenings that are part of a preventive visit — certain cholesterol panels, blood pressure checks, recommended cancer screening tests rated A or B by the U.S. Preventive Services Task Force (USPSTF) — are also covered without cost-sharing when ordered as preventive services 1Ref 1U.S. Department of Health and Human Services (2024).Preventive Care | HHS.gov.ACA requirement that non-grandfathered health plans cover USPSTF A/B-rated preventive services and annual wellness visits at zero cost-sharing when in-network.

However, if additional labs are ordered because of a concern your doctor has (for example, a blood sugar test ordered because you report symptoms, not just as routine age-appropriate screening), those may be billed as diagnostic labs and subject to your deductible. Always ask whether a test is being submitted as preventive or diagnostic.

How do I prepare to avoid a surprise bill?

Before the appointment: Call your insurer and confirm that a preventive care visit with your specific provider is fully covered. Ask whether the provider is in-network.

During the visit: Tell your doctor at the start which concerns you want to discuss, so they can help you understand how the visit will be coded before proceeding.

After the visit: Review your Explanation of Benefits (EOB) — the document your insurer sends once the claim is processed — to confirm the coding matches what was discussed. If something looks wrong, you have the right to appeal 3Ref 3U.S. Centers for Medicare and Medicaid Services (2024).Summary of Benefits and Coverage and Your Rights to Appeal.Patient right to receive an Explanation of Benefits (EOB) and to appeal incorrect claim coding; ACA requirement for insurers to provide SBCs disclosing coverage rules.

Does Medicare work the same way?

Not exactly. Medicare covers an Annual Wellness Visit, but it does not cover the traditional comprehensive "head-to-toe" physical as a separate benefit. If your doctor performs a comprehensive physical examination beyond the structured wellness visit, you may be billed for that additional service. The Welcome to Medicare visit is a one-time benefit for new Part B enrollees.