How Much Does a Doctor Visit Cost With and Without Insurance?
Without insurance, medical care can get pricy fast. Where you live, what doctor you’re going to, and what tests you need will all figure into your doctor’s visit bill. In this article, we’ll break down those costs and give you some tips for saving money.
What Goes into the Cost of a Doctor’s Visit?
Geography is one of the biggest factors in the price of a doctor’s visit. Most medical facilities pass some of their overhead expenses onto their patients. If you live somewhere with a higher cost of living, like California or New York City, you’ll likely pay more for doctors’ visits. The practice has to pay more for utilities and rent, and those costs show up in your bill. For example, Mayo Clinic’s Patient Estimates tool quotes $846 for a 60-minute office visit in Jacksonville, Florida, but $605 for the same visit in Wisconsin.
Like the cost of living, supplies and equipment will also end up on your tab. Say you need a strep test, blood draw, or Pap smear. The supplies needed for the test plus the cost of the lab fees will all figure into the price.
Bills for the same exams and procedures can also vary depending on what kind of facility you’re going to. Smaller practices and public health centers are often a lot cheaper than university or private hospital systems. This is due in part to their buildings being smaller and their overhead fees being lower.
Price of Out-of-Pocket Doctors’ Visits
The cost of a doctor’s office visit also depends on what kind of doctor and the procedure you need to have done. For example, an in-office general wellness checkup will be cheaper than a specialist procedure. If you have an emergency, an urgent care center will be much more affordable than the emergency room.
Primary Care Physician — Physical Exam
Physicals usually include blood pressure readings, cholesterol measurements, and vaccines. Prostate exams for men and Pap smears and breast exams for women are also often included. Pediatric physicals focus on the growth milestones for your child’s age. Doctors check height, weight, sleep patterns, diet, and the vaccines required by public schools.
The range for a yearly physical can be anywhere from $100 to $250 or more without insurance. A CVS Minutecare Clinic may charge just $59 for a sports physical, but not all organizations will accept this as proof of physical health.
Primary Care Physician — Procedures
On top of the base cost for physical exams, you may have extra charges for any specific tests or procedures you need. According to the Cardiometabolic Health blog, the most common procedures in primary care medicine include bloodwork, electrocardiograms, and vaccines/injections.
Bloodwork is one of the biggest cost wild cards. Certain tests can run you from as little as $10 to as much as $10,000 . Large national labs like Labcorp offer pricing on their website, so you know what to expect going in. For example, Labcorp’s General Health Blood Test , which includes a metabolic panel, complete blood count (CBC), and urinalysis, costs $78.
Electrocardiograms or EKGs check your heart health and can find cardi ac issues. This quick procedure involves monitoring your heartbeat through electrodes placed on your skin. While it’s a painless and accurate way to detect heart conditions, the costs can add up without insurance. Expect to pay as little as $410 or as much as $1700 for this procedure, depending on local prices.
Vaccines are often required before sending your kids to school. The CDC publishes a vaccination price list annually to give you an idea of what to expect. For example, they quote $19-$132 for DTaP, $21 for Hepatitis A, and $13-$65 for Hepatitis B. The COVID-19 vaccine, however, is free of cost, regardless of insurance status.
Urgent Care Visit
If you have an emergency but are stable, urgent care is much cheaper than the emergency room. According to Scripps , most urgent care centers and walk-in clinics can at least treat dehydration, cuts or simple fractures, fever, flu, strep, and UTIs. Note that if you have chest pain, a serious injury, seizures, a stroke, or pregnancy complications, you should go straight to the ER .
For a base exam at an urgent care facility, expect to pay between $100-$150 . That price will go up depending on what else you need. For example, Advanced Urgent Care in Denver quotes $80 for an X-Ray, $50 for an EKG, $135 for stitches, and $5 for a urinalysis. In comparison, expect to pay $1,000-$1,300 for the same procedures in the emergency room.
How to Lower Your Out-of-Pocket Medical Costs
Healthcare expenses may seem overwhelming without insurance. Luckily, there are many resources available to help you cover the costs.
Free & Low-Cost Immunization and Wellness Clinics
For standard vaccines and checkups, look for local free or low-cost clinics. Check out The National Association of Free and Charitable Clinics’ search tool to find a location near you. Your city’s public health department should also offer free or low-cost vaccines and basic medical care services.
Certain large vaccine manufacturers also offer vaccine programs. For example, Merck’s patient assistance program offers 37 vaccines and medicines free to eligible patients. The program includes albuterol inhalers and vaccines for Hepatitis A, Hepatitis B, MMR, and HPV.
Cash Negotiations
Most health systems offer lower rates for patients paying cash. Some even have free programs for low-income families. For example, Heritage UPC in North Carolina has a yearly membership for low-cost preventative care. In Northern California, the Sutter Health medical system offers full coverage for patients earning 400% or less of the Federal Poverty Income Guideline .
As of January 1, 2021, all hospitals in the United States now have to follow the Hospital Price Transparency Rule . That means they have to list procedure prices clearly on their website. You can also call medical billing before your appointment to discuss cash pay options.
Federal Medical Payment Support
If all else fails, there are federal programs to help you cover the cost of medical bills.
Organizations like The United Way and United for Alice offer grants for ALICE (asset-limited, income-constrained, employed) patients. These are people living above the poverty level, making them ineligible for other government programs but below the basic cost-of-living threshold.
Medicaid is available for children, pregnant women, and adults under a certain income threshold. If your income is too high to qualify for Medicaid but you can’t afford private insurance for your children, you may be eligible for the Children’s Health Insurance Program (CHIP) to cover your children’s medical care.
Use Compare.com for the Best Doctors’ Visit Prices
Navigating bills for a doctor’s visit can feel overwhelming, but Compare.com is here to help. With our price comparison tool, you can search all clinic and doctors’ office prices in your area. Compare makes sure you’re prepared for the cost of your checkup long before you schedule your appointment.
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What is the difference between a physical exam and a Medicare Wellness Visit?
Published by Medicare Made Clear®
The difference between a physical exam and a Medicare Wellness Visit is basically the difference between your doctor focusing on what’s wrong versus on what’s right. Each is important, depending on the situation.
When you’re sick or in pain, you want to get better. A physical exam helps your doctor figure out what the problem is and what needs to be done.
When you’re healthy and feeling good, you want to stay that way. A wellness exam helps your doctor understand what’s working for you and how to best support your continued health and well-being.
Your doctor performs specific tasks in each of these two exams in order to achieve its purpose. See below for a chart that lists some of the services that may be covered in a physical exam versus a Medicare wellness visit, or that may be covered in both.
NOTE: this chart is not complete and you should ask your physician what is covered and your Medicare plan provider to understand how different health services may or may not be covered.
What’s included in a physical exam?
An annual physical exam is an assessment of your body’s health. The primary purpose is to look for health problems.
During the exam, your doctor uses his or her senses – mainly sight, touch and hearing – to gauge how your body is performing. Based on what’s learned, your doctor may ask you to have tests to discover or rule out possible health problems.
The list below shows some of the things your doctor may do during a physical exam.
Visually check your body overall for signs of existing health issues
Look into your eyes, ears, nose and throat for potential problems
Listen to your heart and lungs to detect irregular sounds
Touch parts of your body to feel for abnormalities
Test your motor function and reflexes
Perform pelvic and rectal exams
Measure your height, weight and blood pressure
As a rule, Medicare does not cover an annual physical. The exam and any tests your doctor orders are separate services, and you may have costs related to each depending on your Medicare plan.
What’s included in a Medicare Wellness Visit?
A Medicare Wellness Visit, also called a wellness exam, is an assessment of your overall health and well-being. The primary purpose is prevention – either to develop or update your personalized prevention plan. Medicare covers a wellness visit once every 12 months (11 full months must have passed since your last visit), and you are eligible for this benefit after you have had Part B for at least 12 months.
During the exam, your primary care provider combines information from the visit with your medical record to gauge your risk for common preventable health problems such as heart disease, cancer and type 2 diabetes. Based on what’s learned, your doctor creates your personal prevention plan with a checklist of screenings you need to have.
The list below shows some of the things your doctor may do during a wellness exam.
Review your health risk assessment (questions you answer about your health)
Confirm your medical and family history
Record your current prescriptions and providers
Measure and document your height, weight, and blood pressure
Look for signs of memory loss, dementia, or frailty
Document your health risk factors and treatment options
Provide personalized health advice
Develop a screening schedule (like a checklist) for the preventive services recommended for you
Medicare Part B covers an annual wellness exam and many preventive screenings with no copay or deductible. However, you may have to pay a share of the cost for certain recommended tests or services. And while it’s not mandatory, there are very good reasons to have a wellness exam every year.
What is a "Welcome to Medicare" visit?
Medicare Part B covers a "Welcome to Medicare" visit. This visit is also called an Initial Preventive Physical Exam (IPPE). You are eligible for this benefit once within the first 12 months you are enrolled in Part B
What to expect at your "Welcome to Medicare" visit
During the visit your provider will:
Record and evaluate your medical and family history, current health conditions and prescriptions.
Check your blood pressure, vision, weight and height to get a baseline for your care.
Make sure you are up-to-date with preventive screenings and services, such as cancer screenings and shots.
Order further tests, depending on your general health and medical history.
You do not pay a copayment for your "Welcome to Medicare" visit. The Part B deductible does not apply to the cost of the visit either.
After the visit, your provider will give you a personalized prevention plan or checklist with the screenings and preventive services recommended for you. These services are not part of the "Welcome to Medicare" visit. You may have to pay a co-payment for the recommended services when you get them. Your Part B deductible may also apply.
Learn more about what to expect at your Medicare wellness visit.
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In the exam room, the distinction between one type of visit and another isn't always clear. It's important to know when — and how — you can bill for both .
BETSY NICOLETTI, MS, CPC, AND VINITA MAGOON, DO, JD, MBA, MPH, CMQ
Fam Pract Manag. 2022;29(1):15-20
Author disclosures: no relevant financial relationships.
In family medicine, it's common for a medical problem to crop up during a routine preventive visit, or for a preventive service to crop up during a problem-oriented visit. For example, let's say you're finishing up a Medicare annual wellness visit when the patient lifts his shirt and says, “Oh yeah, I'd also like you to look at this rash,” which results in a prescription. Or, at a follow-up visit for a patient's chronic condition, you notice he is overdue for a flu shot and colorectal screening, so you perform a preventive visit too.
From a coding perspective, there is a bright line between a preventive medicine visit and a problem-oriented visit. One is for promoting health and wellness, and the other is for addressing an acute or chronic medical problem. But in the exam room, the distinction isn't always clear. The question for family physicians is this: When does the work in the exam room warrant billing for two distinct services?
The answer lies in knowing the requirements for various preventive medicine and Medicare wellness visits, knowing when you've done enough beyond those requirements to also bill for a separate E/M service, and knowing how to document and code it all. The good news is the 2021 E/M coding changes made it easier than it used to be.
When physicians and other clinicians address a medical problem during a preventive or wellness visit, they can often bill for both services.
Knowing the core components of preventive or wellness visits can help physicians recognize when they have done enough work beyond those requirements to bill for a separate evaluation and management service.
Because preventive and wellness visits come with no cost sharing, it's best practice to explain to patients that a separate service performed during the same visit may result in a charge to them.
PREVENTIVE MEDICINE VISITS
Preventive medicine visits (CPT codes 99381-99397) are for patients covered by commercial insurance, Medicaid plans, and some Medicare Advantage plans. Patients value these visits because they are not subject to co-pays and deductibles. After age two, one preventive visit is covered annually.
According to CPT, preventive medicine visits are “comprehensive preventive medicine evaluation and management services of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures.”
Codes 99381-99387 are for new patients and 99391-99397 are for established patients. Both are further broken down by age group. The extent of the exam, the content of the counseling and anticipatory guidance, and the recommended screenings and immunizations vary depending on the patient's age and gender. “Comprehensive” in the CPT definition is not synonymous with the comprehensive exam required in other E/M services. This is a common misconception among physicians and patients alike.
CPT states that if a new or existing problem is assessed and managed at the time of the preventive visit, the physician should also bill a problem-oriented visit (an office visit) on the day of the preventive care. But insignificant problems that do not require extra work should not be billed as office visits. If a patient comes in for a preventive visit and the clinician also looks at a rash or notices the patient's blood pressure is elevated, these observations alone are not enough to bill a problem-oriented E/M visit. There must be some medical decision making (MDM) that occurs, such as prescribing a topical treatment for the rash or choosing not to prescribe a medication for the high blood pressure and instead suggesting the patient change his diet.
Once you've documented your MDM, you can bill an E/M visit using codes 99202-99215 with the preventive medicine visit code. Make sure to add modifier 25 to the E/M code to signal to the payer that two distinct visits were done on the same day.
For more details on when to bill both visits, how to level the E/M portion, and what to include in your documentation, see “ One visit or two? ”
ONE VISIT OR TWO?
Medicare wellness visits.
Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits. However, a Medicare wellness visit and a preventive visit should not be billed on the same date of service. Medicare developed the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare” visit) (G0402) and initial and subsequent annual wellness visits (G0438 and G0439) to encourage Medicare patients to receive screenings and preventive care, and to work with their physicians to develop a personalized prevention plan. 1 The requirements are slightly different for the three codes, but in general they require collecting or updating medical, family, and social history; screening for depression; evaluating the patient's ability to perform activities of daily living; assessing the patient's safety at home; recording vital signs; asking about opioid and substance use; and providing guidance about preventive services and a personalized prevention plan (for more details, see the table in “ Medicare 101: Navigating the Rules for Coverage and Benefits in Clinical Practice ”). Similar to CPT's preventive medicine visits, Medicare wellness visits do not require a full head-to-toe physical exam.
The assessment and management of acute or chronic problems are not components of the IPPE or annual wellness visits. When that service is medically necessary during a Medicare wellness visit, the physician can also bill for a problem-oriented E/M office visit on the same day, again using the appropriate CPT code (99202-99215) with modifier 25.
SELECTING THE LEVEL OF SERVICE FOR THE E/M CODE
Hopefully you're now familiar with the E/M coding rules that changed in 2021. 2 Performing a problem-oriented E/M service on the same date as a wellness visit adds a layer of complexity when it comes to choosing the level of service for the E/M code. But, as mentioned, the new rules actually make it easier than it was before.
When selecting a code (99202-99215) using the new E/M guidelines for office and outpatient services, physicians may use either total time on the date of the visit or MDM. History and exam are no longer necessary to select the level of service (though they should still be documented to provide the best care). This makes it easier to select a level of service for the problem-oriented visit when it's combined with a wellness or preventive visit because there are fewer overlapping components when coding based on MDM. The E/M service is your assessment and management of an acute or chronic condition, which is not required in either CPT preventive services or Medicare wellness visits.
It's trickier to code the E/M service based on time because you must make sure to only count the time spent managing the problems, not the time spent on the preventive or wellness service. The February 2021 CPT Assistant newsletter was particularly clear on this, stating “if time is used for selection of a level of the office/outpatient E/M code, the time spent on the preventive service cannot be counted toward the time of the work of the problem assessment because time spent performing a service cannot be counted twice. The code for the problem-assessment portion of the encounter will likely be selected based on MDM.” 3 It might make sense to consider MDM-based coding as the best practice when combining E/M visits with wellness visits.
A problem-oriented visit includes the history of the problem and any symptoms or complaints related to it. It may or may not include a physical exam or data review (e.g., notes reviewed, tests ordered, tests reviewed, or independent historian). It includes the evaluation and management of a problem or condition. When these components are documented in addition to the preventive visit, add a problem-oriented visit code. For more on which components are required for which visits, see “ How to credit combined visits .”
Let's look at some examples of when it would be appropriate to bill for a problem-oriented E/M code (CPT 99202-99215) along with a preventive or wellness visit.
Patient 1: A 70-year-old male, established patient with a history of diabetes and hyperlipidemia comes in for a Medicare annual wellness visit. All required components of the wellness visit are completed. The patient then asks for a refill of his diabetes medication. The physician asks the patient if he is taking his medication as prescribed and following the diet recommendations discussed during the last visit. The physician also performs a focused physical exam, discusses medication management for diabetes and hyperlipidemia, and orders maintenance labs. The physician documents her significant review of the patient's problems, bills for the annual wellness visit with code G0439, and adds a 99214 E/M code because she addressed two stable chronic illnesses and performed prescription drug management. She adds modifier 25 to the E/M code.
Patient 2: A 32-year-old female, new patient comes in for a preventive medicine visit required by her employer. The physician completes all requirements for the preventive visit. During the history portion, the patient tells the physician that she has been having some knee pain exacerbated by running. The physician obtains additional history about the pain, examines her knee, tells her to reduce her running until the pain subsides, and gives her a handout on knee exercises. He also recommends she try a knee brace and follow up if the pain does not lessen with rest. The physician documents the extra work done to address the knee issue, then bills code 99385 for an initial preventive medicine visit for a patient age 18–39, along with E/M code 99203 because he addressed one acute, uncomplicated injury. He adds modifier 25 to the E/M code.
Patient 3: A 49-year-old female, established patient comes in for her annual preventive visit. The physician completes all requirements for the preventive visit. The patient then mentions she has been excessively tired recently and has been having trouble sleeping. The physician obtains a detailed history of the problems, does a thorough physical exam, and orders some labs (complete blood count and thyroid-stimulating hormone). The physician documents the extra work, then bills code 99396 for a periodic preventive medicine visit for a patient age 40–64 and E/M code 99213 for addressing two acute illnesses (fatigue and insomnia) and ordering two labs. The physician adds modifier 25 to the E/M code.
WORKFLOW TIPS
It's hard to plan for surprise problems that come up during a preventive or wellness visit. But your staff can help by asking patients up front if they have any other issues that need to be addressed. This step should occur when staff are scheduling or confirming patient visits, allowing you to block off more time if necessary.
Scheduling staff should also be aware that Medicare wellness visits have strict rules about how often they can be billed. They must be separated by at least 12 months from the previous wellness visit. Having staff check eligibility for Medicare wellness visits using the HIPAA Eligibility Transaction System can help you avoid denials. 4 The timeframes for CPT preventive visits are more forgiving; they can be performed once every plan year (usually a calendar year, but some plans vary).
Patients who know their preventive/wellness visit will be covered with no deductible or co-pay may mistakenly assume all services provided during that visit, including E/M, will be no cost to them. It is best to educate patients on the costs associated with a problem-oriented office visit and let them know that performing one with a preventive or wellness visit will result in the same co-pay they would incur if the problem-oriented visit was on a different day. Most patients will accept this, because getting both visits in the same trip is more convenient for them. Posting flyers in the exam rooms or waiting room about the difference between preventive/wellness visits and problem-oriented visits, and the costs associated with each, can also prevent patient dissatisfaction.
Physicians could ask these patients to return for the problem-oriented visit on another day, but if time allows for providing both services at the current visit, it is only fair and reasonable to do so. Knowing the rules for combined visits, and the convenience they offer patients, should give physicians the confidence to bill fully for their services.
The ABCs of the Initial Preventive Physical Examination. Medicare Learning Network. Accessed Nov. 15, 2021. https://www.mvphealthcare.com/wp-content/uploads/download-manager-files/CMS-ABC-Initial-Preventive-Physical-Examination-ICN006904-01-2015.pdf
Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.
Evaluation and management (E/M) 2021; AMA CPT Assistant . 2021;2:7-8.
HIPAA Eligibility Transaction System (HETS). Centers for Medicare & Medicaid Services. Updated Oct. 25, 2021. Accessed Nov. 15, 2021. https://www.cms.gov/research-statistics-data-and-systems/cms-information-technology/hetshelp
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Will I Have to Pay My Deductible Before I Can Get Medical Care?
- The Old Way
- Why They Bill Upfront
- Handling Upfront Bills
- Can They Deny Care?
Increasing Deductibles
Consider an hsa.
Over the last few years, it's become more common for hospitals and other medical providers to ask people to pay their deductibles before medical services are provided. According to one recent analysis, at least three-quarters of hospital systems in the U.S. ask patients to prepay some or all of their out-of-pocket costs for certain services, including things like MRIs, CT scans, and even births.
This article will help you understand why this is happening, what rights you have, and how to navigate our current healthcare system.
The Way It Used to Be
In the past, it was generally accepted that patients were expected to pay their copays at the time of service, but charges that counted towards the deductible would be billed after the fact.
So, if your health plan had a $20 copay for an office visit, the doctor's office would collect that when you arrived for the appointment.
However, if your plan had a $2,000 deductible and you were going in for surgery, you'd pay nothing at the time of the surgery but would get a bill from the hospital a few weeks later.
First, they would send the claim to your insurer, where the network negotiated rate would be calculated and amounts over that would be written off. Then the insurer would pay their portion, and notify the hospital about your portion of the bill (you would also receive an explanation of benefits with the same information).
At that point, the hospital and medical providers would send you a bill (or multiple bills, depending on the care that was provided) for your deductible and any applicable coinsurance.
Why They're Billing Upfront
Depending on the service you're receiving and how much it costs relative to your deductible, many medical facilities and professionals still use the traditional method of waiting to send you a bill until after your procedure is complete and your insurance company has processed your bill.
It's becoming increasingly common, though, for medical providers to ask for payment of your deductible—partial or in full—before scheduled medical services are provided. This is due to a variety of factors, including increasing medical costs, as well as rising deductibles and total out-of-pocket costs.
Medical providers don't want to be stuck with unpaid bills, and they know after the procedure is completed, people may not pay what they owe. The medical provider can send them to collections or file a lawsuit against the patient. However, obtaining payment upfront is a more effective method of ensuring that the bill gets paid.
Hospitals are also increasingly running credit checks on patients. They can then use the information to determine which patients will be likely to pay their bills after the procedure is completed and the claim is processed by the patient's health plan. Using this information, hospitals may ask for upfront payment from some patients but not others.
If They Ask for Payment Upfront
Ideally, you should discuss the timing of payment with the medical provider's billing office well in advance of your procedure. Finding out 18 hours before your surgery that the hospital wants you to pay your $4,000 deductible immediately is stressful, to say the least, and often simply not possible.
If you're scheduling a medical procedure for which your deductible will apply, inquire about the facility's policies right from the start. Talk with your health plan to see if they have any contract negotiations with this medical facility that require the bill to be sent to the insurer before the patient is charged.
If not, the hospital, clinic, or medical provider may very well want you to pay at least a portion of the deductible ahead of time or when you arrive for the medical procedure ( here's an example of how this works , from the University of Wisconsin Hospital system).
But in general, network contracts between insurers and medical providers will prohibit the medical providers from requiring payment of deductibles before medical services are provided. They can certainly ask for it, and patients have the option to pay some or all of their deductible upfront. But your health plan likely prohibits in-network medical providers from denying care if you can't or don't want to pay your deductible ahead of time.
If in doubt, it's wise to contact your health plan and your state's insurance department to see if they have any advice about contract rules and state regulations that pertain to medical billing practices (note that state insurance regulations don't apply to self-insured group plans , as those are federally regulated under ERISA). The more you know, the better you'll be able to navigate the system.
How Much Will You Actually Owe?
Ask the hospital to provide you with an estimate of what you'll owe, keeping in mind that negotiated medical costs tend to be far lower than retail costs. And double check their estimate with your health plan, to see if they're roughly the same.
The federal government has rolled out some new pricing transparency rules over the last few years, which make it easier for consumers to have access to health care costs in advance (as opposed to having to wait for the explanation of benefits after the procedure is completed). Hospital price transparency rules took effect in 2021 and health plan price transparency rules were fully in place by the start of 2024.
The medical facility might not know in advance exactly what care they're going to have to provide, since this sometimes depends on what they encounter during the procedure. But for the care they know you'll need, make sure you understand the negotiated rate that your health plan has with this medical provider for that specific service.
For example, let's say your deductible is $5,000, you've paid nothing toward it this year, and you're scheduling an MRI.
The average cost of an MRI in the U.S. is about $1,325, although it varies considerably from one facility to another. It's also important to note that what the facility charges is likely to be quite a bit higher than the rate your insurer has negotiated with that facility.
The facility might bill $2,000, but the insurer's negotiated rate might be $1,050. In that case, the amount you would have to pay towards your deductible would be $1,050, not $2,000 .
This isn't an issue if you're having a procedure that's many times more costly than your deductible. If you're about to have a knee replacement, which averages about $34,000, and your deductible is $5,000, you will have to pay the full deductible.
The hospital might ask you to pay all or part of it upfront, or they might bill you after they submit the claim to your insurer, but there's no getting around the fact that you're going to have to pay the full $5,000, and you won't save any money by waiting to pay your bill until after the claim is processed.
Note that coinsurance is different since it's a percentage of the total amount that the health plan has negotiated with the medical provider. Since coinsurance isn't a flat amount, it's particularly important to wait to pay coinsurance charges until the claim has been processed. The exception would be a situation in which you know that you'll meet your health plan's total out-of-pocket limit . In that case, even if you pay it all upfront, it won't be any more expensive than it would have been if you had waited for the claim to be processed.
In the previous example about the MRI, however, the actual amount you'll have to pay isn't certain until your insurer has processed the claim. But again, the health plan price transparency rules ensure that you can find out, in advance, how much your health plan's negotiated rate is for an MRI at the facility you're using.
If the medical provider is asking you to pay a portion of your deductible in advance, and it's unclear how much you'll actually owe, discuss the situation with your insurer before giving any money to the hospital. Make sure that the amount the hospital is asking you to prepay is the rate that your insurer has negotiated with them, as opposed to their retail rate.
Check with your insurer to make sure that their contract allows you to reject the medical provider's prepayment request. You should be able to wait until the claim is sent to your insurance plan and the price adjusted in line with the network contract. At that point, you'll receive an accurate bill from the hospital, which you should pay as soon as possible.
One way or another, you'll want to make sure that you're only paying the amount that your insurer's explanation of benefits will ultimately say that you owe, rather than the amount that the medical provider charges.
Denying Care Based on Ability to Pay
There's sometimes a misconception about hospitals' obligations to provide care regardless of a patient's ability to pay.
Since 1986, the Emergency Medical Treatment and Labor Act ( EMTALA ) has required all Medicare-accepting hospitals (virtually all U.S. hospitals) to provide screening and stabilization services to anyone who arrives in the emergency room—including pregnant people in active labor—regardless of their insurance status or ability to pay for care.
The emergency room is required to:
- Screen you to determine the problem
- Provide stabilization services (e.g., They can't let you bleed to death due to lack of funds.)
They don't have to provide anything beyond that if they're not certain you can pay for it, and EMTALA doesn't extend to any care beyond emergency services.
So a pre-scheduled medical procedure won't be subject to any rules that require hospitals to provide care regardless of the patient's ability to pay.
But if you're covered under Medicare, federal rules do ensure that you can't be denied care due to a failure to prepay your anticipated out-of-pocket costs. The Centers for Medicare and Medicaid Services clarify that: " Except in rare cases where prepayment may be required, any request for payment must be made as a request and without undue pressure. The beneficiary (and the beneficiary’s family) must not be given cause to fear that admission or treatment will be denied for failure to make the advance payment ."
And if you have private coverage, your health plan's contract with the medical provider may prohibit them from requiring that you pay your deductible ahead of time. However, if you haven't paid previous medical bills and still owe money to the facility, they may refuse to continue to treat you.
The ACA limits how high in-network out-of-pocket costs can be , but the limit itself is fairly high. In 2024, health plans can have out-of-pocket costs as high as $9,450 for an individual and $18,900 for a family.
Many health plans have out-of-pocket limits well below those amounts, but deductibles on individual market plans are often multiple thousands of dollars ( cost-sharing reductions lower these deductibles for eligible people, as long as they select a silver plan in the exchange).
Employer-sponsored plans have to abide by the ACA's cap on out-of-pocket costs too, but they tend to have deductibles and out-of-pocket costs that are lower than those in the individual market. In 2023, the average deductible for people with employer-sponsored health insurance was $1,735 for a single person.
Yet the Federal Reserve reported in 2023 that about 37% of U.S. adults would not be able to come up with $400 to cover an unexpected bill, or would have to sell something to cover the cost.
That presents a conundrum when people have an unexpected but necessary medical procedure and a fairly high deductible. It also presents a conundrum for hospitals and medical professionals—tasked on one hand with providing health care to residents, but also needing to generate enough revenue to stay financially viable.
Requiring upfront payment of at least part of the deductible is one way for hospitals to avoid situations in which patients end up unable to pay their bills.
If your employer offers an HSA-qualified high deductible health plan (HDHP), or if you're purchasing your own health insurance in the individual market, consider enrolling in an HDHP. They aren't the right fit for everyone, but if you're covered by an HDHP, you can contribute pre-tax money to an HSA , and it will be there if and when you need it.
In 2024, you can contribute up to $8,300 to an HSA if you have family coverage under an HDHP, and up to $4,150 if you have self-only coverage under an HDHP.
Even if you can only contribute a small amount each month, it will add up over time, and there's no "use it or lose it" provision—the money remains in your account until you need to withdraw it.
You can build up a cushion in an HSA while you have coverage under an HDHP, and withdraw it later to cover future medical expenses, even if you no longer have HDHP coverage at that point.
The takeaway is this: If you have access to an HSA-qualified plan, enrolling and making contributions will make it easier to deal with a potential future situation in which a hospital suddenly asks you to pay a significant chunk of money upfront before you can get medical care. And you'll be able to pay the bill with pre-tax money, which could result in significant savings, depending on how much you owe.
Depending on a patient's health plan, credit history, medical needs, and choice of hospital, the patient may be asked to pay some or all of their deductible upfront, before receiving medical care. Hospitals cannot do this in situations that are covered by EMTALA, but that law only requires an emergency department to assess and stabilize the patient. In other situations, including a pre-scheduled surgery, the hospital or other providers can ask for at least some payment upfront.
But in most cases, a health plan's network contract with the hospital or other medical provider will allow them to request upfront payment of deductibles, but not to require it. So patients need to understand their rights. And if they do prepay deductible and/or coinsurance charges, it's important to ensure that they won't pay more than the network negotiated price for the service they'll receive.
A Word From Verywell
If you're scheduling a medical procedure and are concerned about the cost, the best course of action is to speak up, sooner rather than later. If you think you might have trouble coming up with the amount of your deductible, you may be able to work out a payment plan in advance. If you're asked for an upfront payment and you don't feel comfortable with this, check with your health plan to see if their contract with the hospital prohibits the requirement that deductibles be paid ahead of time.
Wahlberg, David. Wisconsin State Journal. Bill Comes Before Baby, As Hospitals Seek Advance Payments From Patients .
Buck, Isaac D. Hastings Law Journal. Volume 73, Issue 2, Article 2. When Hospitals Sue Patients . February 2022.
Centers for Medicare & Medicaid Services. Hospital Price Transparency . Accessed February 17, 2024.
Centers for Medicare & Medicaid Services. Transparency in Coverage . Accessed February 17, 2024.
Vanvuren, Christina. New Choice Health. What can affect the cost of an MRI?
Claxton, Gary; Rae, Matthew; Levitt, Larry; Cox, Cynthia. Kaiser Family Foundation. Peterson-Kaiser Health System Tracker. How have healthcare prices grown in the U.S. over time?
Centers for Medicare and Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA) .
Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual Chapter 2 - Admission and Registration Requirements .
HealthCare.gov Glossary. Out-of-Pocket Maximum/Limit .
Kaiser Family Foundation. 2023 Employer Health Benefits Survey .
Board of Governors of the Federal Reserve System. Report on the Economic Well-Being of U.S. Households in 2022 - May 2023 .
Internal Revenue Service. Revenue Procedure 2023-23 .
By Louise Norris Louise Norris has been a licensed health insurance agent since 2003 after graduating magna cum laude from Colorado State with a BS in psychology.
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Common questions about Medicare annual wellness visits
If you are a Medicare recipient, you can take advantage of annual wellness visits. These visits are a preventive health benefit available after having Medicare Part B coverage for at least one year. All Medicare Advantage Plans are required to offer annual wellness visits for their members. A nurse or nurse practitioner reviews your health status and helps you plan for health and wellness needs.
In most cases, the annual wellness visit will be followed by a separate medical visit with your primary care professional to close any health care gaps and address any problems identified during the visit.
Here are answers to common questions about annual wellness visits.
Why are annual wellness visits important.
The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms. It also allows your primary care professional more time to focus on your medical concerns and needs at a separate physical exam.
Do I need to be 65 or older to have an annual wellness visit?
You do not need to be 65 or older to qualify for an annual wellness visit as long as you've been on Medicare Part B for at least one year.
How is an annual wellness visit scheduled?
If you are due for an annual wellness visit, you may be prompted to self-schedule the visit in the patient portal . You also may call your care team and ask to be scheduled.
If your visit is with a nurse or nurse practitioner, it's recommended to schedule this visit before the visit with your primary care professional. This allows your primary care professional the chance to address any concerns mentioned during your annual wellness visit.
How can I prepare for my annual wellness visit?
You may be asked to complete some questionnaires before arriving for your appointment, which will be sent to your patient portal account. If you cannot access the questionnaires before the appointment, plan to arrive at your appointment early to complete them.
It's helpful to come prepared to your visit with this information:
- All medications, vitamins and supplements you take, including how much and how often you take them
- Additional medical records, including immunization records
- Dates of your most recent preventive services, like a colonoscopy or mammogram, if completed by another health care facility
- Family health history, with as much detail as possible
- List of medical providers and suppliers who provide you care, equipment or services
What can you expect during an annual wellness visit?
During the visit, you'll meet with a nurse or nurse practitioner to:.
- Evaluate your fall risk
- Measure your height, weight and blood pressure
- Offer referrals to other health education or preventive services
- Provide information related to voluntary advance care planning
- Screen for cognitive impairments like dementia
- Screen for depression
- Update your medical and family history
What is the cost of an annual wellness visit?
Medicare offers the visit at no cost for people who have Medicare Part B coverage for at least one year before the visit. If you are referred for other tests or services, they will be billed to your insurance. If you have a separate visit with your primary care professional following your annual wellness visit, you or your insurance carrier will be responsible for the cost of that visit.
Robert Stroebel, M.D. , is a Community Internal Medicine, Geriatric and Palliative Care physician at Mayo Clinic Primary Care in Rochester and Kasson, Minnesota.
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Paying a Visit to the Doctor: Current Financial Protections for Medicare Patients When Receiving Physician Services
Cristina Boccuti Published: Nov 30, 2016
- Issue Brief
Under current law, Medicare has several financial protections in place that are designed to safeguard Medicare beneficiaries—seniors and people with permanent disabilities—from unexpected and confusing charges when they seek care from doctors and other practitioners. These protections include the participating provider program, limitations on balance billing, and conditions on private contracting. This issue brief describes these three protections, explains why they were enacted, and examines the implications of modifying them for beneficiaries, providers, and the Medicare program.
Main Findings
- The participating provider program was enacted in 1984 for two purposes: (1) to assist Medicare patients with identifying and choosing providers who charge Medicare-approved rates; and (2) to encourage providers to accept these rates. Given this program’s strong provider incentives, the number of participating providers grew rapidly across all states and today, the vast majority (96%) of eligible physicians and practitioners are “participating providers”—agreeing to charge Medicare’s standard fees when they see beneficiaries.
- The Congress instituted limitations on balance billing in 1989, in conjunction with implementation of the Medicare physician fee schedule. This financial protection limits the amount that “non-participating” providers may charge beneficiaries through balance billing—whereby beneficiaries are responsible for the portion of the provider’s charge that exceeds Medicare’s fee-schedule rate. Total out-of-pocket liability from balance billing has declined significantly over the past few decades dropping from $2.5 billion in 1983 ($5.65 billion in 2011 dollars) to $40 million in 2011.
- In 1997, the Congress codified several conditions for private contracting that apply to physicians and practitioners who “opt out” of Medicare and see beneficiaries only under individual private contracts. These restrictions were instituted to ensure that beneficiaries are aware of the financial ramifications of entering into these private contracts, and to safeguard patients and Medicare from fraud and abuse. In general, private contracting is relatively rare with only 1 percent of practicing physicians opting out of Medicare.
Background: Current Provider Options for Charging Medicare Patients
Under current law, physicians and practitioners have three options for how they will charge their patients in traditional Medicare. They may register with Medicare as (1) a participating provider, (2) a non-participating provider, or (3) an opt-out provider who privately contracts with each of his or her Medicare patients for payment (Figure 1). This issue brief describes these three options and then examines three current provisions in Medicare that provide financial protections for Medicare beneficiaries.
Participating providers: Physicians and practitioners who register with Medicare as participating providers agree to “accept assignment” for all of their Medicare patients. Accepting assignment entails two conditions: agreeing to accept Medicare’s fee-schedule amount as payment-in-full for a given service and collecting Medicare’s portion directly from Medicare, rather than the patient. Therefore, when Medicare patients see participating providers, they can be certain that these providers will not charge fees higher than Medicare’s published fee-schedule amount and that they will not face higher out-of-pocket liability than the maximum 20-percent coinsurance for most services. The vast majority (96%) of providers who provide Medicare-covered services are participating providers.
Non-participating providers: Non-participating providers do not agree to accept assignment for all of their Medicare patients; instead they may choose—on a service-by-service basis—to charge Medicare patients higher fees, up to a certain limit. When doing so, their Medicare patients are liable for higher cost sharing to cover the higher charges. This arrangement is called “balance billing” and means that the Medicare patient is financially responsible for the portion of the provider’s charge that is in excess of Medicare’s assigned rate, in addition to standard applicable coinsurance and deductibles for Medicare services. When non-participating providers do not accept assignment, they may not collect reimbursement from Medicare; rather, they bill the Medicare patient directly, typically up front at the time of service. Non-participating providers must submit claims to Medicare on behalf of their Medicare patients, but Medicare reimburses the patient, rather than the nonparticipating provider, for its portion of the covered charges. A small share (4%) of providers who provide Medicare-covered services are non-participating providers.
Opt-out providers, privately contracting: Physicians and practitioners who choose to enter into private contracts with their Medicare patients “opt-out” of the Medicare program entirely. These opt-out providers may charge Medicare patients any fee they choose. Medicare does not provide any reimbursement—either to the provider or the Medicare patient—for services provided by these providers under private contracts. Accordingly, Medicare patients are liable for the entire cost of any services they receive from physicians and practitioners who have opted out of Medicare. Several protections are in place to ensure that patients are clearly aware of their financial liabilities when seeing a provider under a private contract. An extremely small portion of physicians (less than 1% of physicians in clinical practice) have chosen to “opt-out” of the Medicare program, of whom 42 percent are psychiatrists.
These provider options have direct implications on the charges and out-of-pocket liabilities that beneficiaries face when they receive physician services (Figure 2). They also play a major role in several financial protections in current law—namely, the physician participation program, limitations on balance billing, and conditions for private contracting—which help beneficiaries understand the financial implications of their provider choices and encourage providers to accept Medicare’s standard fees.
Figure 1: Physician/Practitioner Billing Options in Traditional Medicare
Figure 2: Medicare reimbursement and beneficiary cost-sharing for a $100 fee-schedule service
Medicare’s Participating Provider Program
Medicare’s participating provider program includes several incentives (both financial and nonfinancial) to encourage physicians and practitioners to “accept assignment” for all of their Medicare patients. When providers accept assignment, they agree to accept Medicare’s fee-schedule amount as payment-in-full for a given service and are allowed to bill Medicare directly for its portion of the reimbursement. Physicians and practitioners who agree to accept assignment on all services that they provide to Medicare patients are “participating providers” and are listed in Medicare provider directories. Beneficiaries who select a participating provider are assured that, after meeting the deductible, their coinsurance liability will not exceed 20 percent of the charge for the services they receive (Figure 2).
Congress established the participating provider program in the 1984 Deficit Reduction Act (DEFRA) to address two main concerns: confusion among beneficiaries about the fees they were being charged when they saw a doctor and escalating rates of balance billing from charges that exceeded Medicare’s established “usual, customary, and reasonable” rates for their area. 1 At that time, aside from Medicaid-eligible beneficiaries, Medicare had no limits on the amount that physicians and practitioners could balance bill for their services. Surveys conducted by the Physician Payment Review Commission (PPRC), a congressional advisory body and predecessor of the Medicare Payment Advisory Commission (MedPAC), revealed that prior to the participating provider program, beneficiaries often did not know from one physician to the next whether they would face extra out-of-pocket charges due to balance billing and how much those amounts might be. 2 By 1984, beneficiaries’ payment for balance billing reached 27 percent of total Medicare Part B out-of-pocket liability and was jeopardizing their access to affordable physician services. 3
The establishment of the participating provider program in Medicare instituted multiple incentives to encourage providers to accept assignment for all their patients and become participating providers. For example, Medicare payment rates for participating providers are 5 percent higher than the rates paid to non-participating providers. Also, participating providers may collect Medicare’s reimbursement amount directly from Medicare, in contrast to non-participating providers who may not collect payment from Medicare and typically bill their Medicare patients upfront for their charges. (Non-participating providers must submit claims to Medicare so that their patients are reimbursed for Medicare’s portion of their charges.) Participating providers also gain the benefit of having electronic access to Medicare beneficiaries’ supplemental insurance status, such as their Medigap coverage. This information makes it considerably easier for providers to file claims to collect beneficiary coinsurance amounts, as well as easing the paperwork burden on patients. Additionally, Medicare helps beneficiaries in traditional Medicare seek and select participating providers by listing them by name with their contact information on Medicare’s consumer-focused website (www.Medicare.gov).
Given the strong incentives of the participation program, combined with limits on balance billing (discussed in the next section), it is not surprising that the share of physicians and practitioners electing to be participating providers has risen to high levels across the country. Overall, the rate of providers with participation agreements has grown to 96 percent in 2011, up considerably from about 30 percent in 1986, two years after the start of the participating provider program (Figure 3). 4 As a result, across all states, most beneficiaries now encounter predictable expenses for Medicare-covered services, and are never responsible for Medicare’s portion of the fee (Appendix 1).
Figure 3: Strong incentives in Medicare have led to a high rate of “participating providers”
Medicare’s Balance Billing Limitations
Despite the incentives to become participating providers, a small share (4%) of physicians and practitioners who are registered with Medicare are non-participating providers. These providers can—on a service-by-service basis—charge patients in traditional Medicare higher fees than Medicare’s fee-schedule amount, up to a specified maximum. When charging higher fees, beneficiaries are responsible for the difference between Medicare’s approved amount and the providers’ total charge—essentially the balance of the bill remaining after accounting for Medicare’s reimbursement. This higher cost-sharing arrangement is called “balance billing” and means that the Medicare patient is financially liable for not only the applicable coinsurance and deductible, but also for any amount in which the provider’s charge exceeds Medicare’s assigned rate. Providers may not balance bill Medicare beneficiaries who also have Medicaid coverage. 5
When non-participating providers balance bill, they bill the beneficiary directly, typically for the full charge of the service—including Medicare’s share, applicable coinsurance and deductible, and any balance billed amount. Non-participating providers are then required to submit a claim to Medicare, so that Medicare can process the claim and reimburse the patient for Medicare’s share of the charge. Two Medigap insurance policies, which beneficiaries may purchase to supplement their Medicare coverage, include coverage for balance billing. 6 Balance billing is prohibited for Medicare-covered services in the Medicare Advantage program, except in the case of private fee-for-service plans.
In traditional Medicare, the maximum that non-participating providers may charge for a Medicare-covered service is 115 percent of the discounted fee-schedule amount. (Medicare’s fee-schedule rates for non-participating physicians are reduced by five percent.) Accordingly, non-participating providers may bill Medicare patients up to 9.25 percent more than participating providers (i.e., 1.15 x 0.95= 109.25). If the non-participating physician or practitioner balance bills the maximum amount permitted (not including any unmet deductible), total beneficiary liability for Medicare-covered services is about 33 percent of Medicare’s regular fee schedule amount (Figure 2).
Balance billing limitations were implemented in conjunction with the institution of Medicare’s physician fee-schedule in the Omnibus Budget Reconciliation Act of 1989. At the time, Medicare’s charge-based methodology for physician services gave rise to rapid spending growth and confusion among beneficiaries about what charges they would face for physician services. 7 Moreover, high cost-sharing liabilities weighed disproportionately on beneficiaries who were sickest and used the most physician services. Despite physician reports that they took patient incomes into account when determining whether to charge higher-than Medicare rates, PPRC research did not find a relationship between beneficiary income and the probability that claims would be assigned. 8
While the Congress constrained growth in provider fees through the implementation of the fee schedule, it also implemented maximum “limiting charges” to establish further certainty and predictability for patients on their expected costs for services. In trying to rein in Medicare fee-schedule payments, the Congress sought to protect beneficiaries from excess charges that providers could otherwise impose in response to restrictions on their fees. 9
The continued desire to protect beneficiary spending during the implementation of the new physician fee schedule gave rise to the question of whether Congress might consider imposing even greater restrictions on balance billing or even mandate assignment (prohibiting balance billing) for all claims. 10 Ultimately, the rationale in Congress for allowing limited balance billing was that it would provide for: (1) a “safety valve” for physicians who believed that the fee schedule did not adequately reflect the quality of services that they provided; (2) a means to correct any underpricing of resource costs in the fee schedule; and (3) necessary financial protections for beneficiaries, particularly in areas of the country where choice of physicians was limited. 11
As limits on balance billing were implemented and incentives for physicians and practitioners to take assignment took hold, beneficiary liability for balance billing declined dramatically. CMS data show that in 2011, total balance billing amounted to $40 million, down significantly from $2.5 billion in 1983, (which equals $5.6 billion in 2011 dollars) (Figure 4). Concurrently, the rate of assigned claims to total covered charges climbed from 51% in 1983 to 99% in 2011.
Figure 4: Balance billing in Medicare has declined significantly; almost all physician services are now paid on assignment
Private Contracting Conditions for Providers who Opt Out of Medicare
A very small share of providers (less than 1 percent of physicians) have elected to “opt out” of Medicare and contract privately with all of their Medicare patients, individually. 12 Their fees are not bound by Medicare’s physician fee schedule in any way, which means that these providers have no limits on the amounts they may charge beneficiaries for their services. Medicare does not reimburse either the provider or the patient for any services furnished by opt-out providers. Therefore, Medicare patients are financially responsible for the full charge of services provided by providers who have formally opted out of Medicare. 13
Serving as beneficiary protections, several important conditions exist for providers who elect to contract privately with Medicare patients. One condition is that prior to providing any service to Medicare patients, physicians and practitioners must inform their Medicare patients that they have opted out of Medicare and provide their Medicare patients with a written document stating that Medicare will not reimburse either the provider or the patient for any services furnished by opt-out providers. Their Medicare patients must sign this document to signify their understanding of it and their right to seek care from a physician or other practitioner who has not opted-out of Medicare.
Providers opt-out by submitting a signed affidavit to Medicare agreeing to applicable terms and affirming that their contracts with patients include all the necessary information. Physicians or practitioners who opt out of Medicare must privately contract with all of their Medicare patients, not just some. Once a physician or practitioner opts out of Medicare, this status lasts for a two-year period and is automatically renewed unless the physician or practitioner actively cancels it. 14 Providers may not enter into a private contract with a beneficiary who also has Medicaid benefits or who is experiencing an urgent or emergent health care event. 15
These conditions, which provide protections for both beneficiaries and the Medicare program, were included in the Balanced Budget Act of 1997 as part of the legislation that first codified physicians’ ability to privately contract with Medicare beneficiaries. Requiring opt-out providers to privately contract for all services they provide to Medicare patients (rather than being able to select by individual patients or services) was intended to prevent confusion among Medicare patients as to whether or not each visit would be covered under Medicare and how much they could expect to pay out-of-pocket. Similarly, requiring providers to opt out for a minimum period of time—two years—was intended to ensure that beneficiaries had consistent information to make knowledgeable choices when selecting their physicians. Both of these provisions also addressed Medicare’s duty to guard against fraudulent billing in an administratively feasibly manner. If, for example, physicians contracted with only some of their patients and/or services, Medicare would have to examine each contract for each submitted claim to discern which claims were eligible for Medicare reimbursement and which were not.
Previous Kaiser Family Foundation analysis shows that psychiatrists are disproportionately represented among the 0.7 percent of physicians (4,863) who have opted out of Medicare—comprising 42 percent of all physicians who have opted out (Figure 5). 16 Another 1,775 clinical professionals with non-physician doctorate degrees (i.e. oral surgeon dentists, podiatrists, and optometrists) also have opted-out of the Medicare program. 17 Dentists who are oral surgeons comprise the majority of this group (95%). Earlier research that examined opt-out providers through 2002 found similarly low numbers of providers opting out (2,839) as well as relatively higher opt-out rates among psychiatrists compared with other specialties. 18
Some physician organizations attribute physician decisions to opt out of Medicare to frustration with Medicare’s fees and regulations. 19 Others have noted a similar trend in physician refusal to work with any insurers—including commercial insurance plans—especially in prosperous communities. 20 In these cases, providers require patients to pay them directly out-of-pocket, leaving the patient to seek reimbursement, if any, from their insurer. For providers with patients who have the resources to make the payments, this billing method significantly reduces providers’ paperwork.
Concierge Practice Models
Some physicians are turning to concierge practice models (also called retainer-based care), in which they charge their patients annual membership fees and typically have smaller patient caseloads. Physicians in a concierge practice model do not necessarily need to opt-out of Medicare to see Medicare patients. However, if they do not opt-out of Medicare, these physicians are subject to Medicare’s balance billing rules, and therefore, cannot charge beneficiaries additional fees for services that are already covered by Medicare. 21 For example, the annual fee for a concierge practice may not be used for the yearly wellness visit covered by Medicare, but it could be applied to items such as a newsletter and high-end waiting room furniture. More controversy exists about concierge practices applying annual fees paid by Medicare beneficiaries to enhanced appointment access and extra time with patients. 22
While anecdotal reports suggest a significant migration of primary care physicians to concierge/retainer practices, particularly in areas around Washington D.C and other major east and west coast cities, reliable data on the number of these practices are lacking. In 2010, a report for MedPAC found listings for 756 concierge physicians, compared with 146 found by Government Accountability Office in 2005. 23 Other news articles have reported larger numbers (4,400 in 2012) according to the American Association of Private Physicians. 24
Implications of Proposals to Modify Incentives and Relax Certain Financial Protections—Pros and Cons
Proposals introduced by Rep. Tom Price, House Speaker Paul Ryan and others have sought to relax private contracting conditions either throughout the Medicare program or as a demonstration project that could be implemented by the Administration. For example, in 2015, two Bills introduced in the House with a companion Bill in the Senate 25 include provisions to allow physicians and practitioners to engage in private contracting on a beneficiary-by-beneficiary basis, instead of requiring providers to opt-out of Medicare entirely. These Bills would also allow beneficiaries to seek Medicare reimbursement for the portion of the privately contracted fee that equals Medicare’s fee schedule amount, but no out-of-pocket limits would apply to the remaining portion of the provider’s charge. Similar changes are also proposed as a demonstration in the 2016 House Republican Plan, “A Better Way, our Vision for a Confident America.” 26 An earlier House Bill also included a demonstration to allow non-participating providers to collect Medicare’s portion of their charge directly from Medicare. 27
Pros: Support for Relaxing restrictions and increasing physician autonomy
Proponents of such proposals, including the American Medical Association, support relaxing restrictions on balance billing and private contracting for a number of reasons—perhaps the foremost is that they would allow physicians to charge Medicare beneficiaries higher rates and thereby get relief from fees that they say have failed to keep pace with the rising costs of running their practices. 28 Proponents also assert that this ability could increase the overall number of providers willing to accept Medicare patients. This concern may be an issue in some geographic areas, though surveys and other data sources show that nationally, access to physicians among Medicare seniors is generally comparable to access among people age 55 to 64 with private insurance. 29
Physician groups also state that proposals to relax constraints on balance billing and private contracting would give providers a sense of greater autonomy in how they relate to both their patients and the Medicare program and would allow physicians to charge higher fees to some patients based on their assessment of their patients’ ability to pay. 30 Additionally, beneficiaries would be able to seek at least partial Medicare reimbursement for services they received under private contracts. Proposals that would allow non-participating providers to collect Medicare’s portion of their charge directly from Medicare would obviate the need to charge patients the full fee upfront. This circumstance could be helpful to those patients who do not want to wait for Medicare’s reimbursement, even if on net, they would incur higher out-of-pocket liability due to balance billing. Non-participating providers could also experience a more reliable payment from Medicare, compared with the challenges, in some cases, of collecting fees from Medicare patients for unassigned claims.
Cons: Concerns about Eroding Financial Protections
Other analysts have raised concerns about the effects of relaxing private contracting rules and balance billing restrictions. 31 To the extent that such changes lead to increases in the number of non-participating and/or opt-out providers, they could exacerbate problems that lower-income beneficiaries face when seeking care. Beneficiaries without the ability to pay higher rates (who are also likely to be disproportionately sicker) could find a reduced pool of physicians willing to accept them. Also, for rarer physician specialties and in some geographic areas, such as rural parts of the country, patients may have little choice among physicians. If the limits on balance billing and private contracting were relaxed, beneficiaries in these situations could face the types of problems that existed prior to the imposition of limits on balance billing—high out-of-pocket costs and greater confusion and uncertainty about possible charges. Additionally, concerns have been raised about the accuracy and appropriateness of providers determining which Medicare patients in their caseload can afford higher fees, and by how much.
While proposals that allow beneficiaries and non-participating physicians to seek reimbursement from Medicare may, in the short term, reduce out-of-pocket liability for beneficiaries, they could also decrease the incentives for physicians and practitioners to become participating providers. In the long run, if significantly more providers balance billed their Medicare patients or opted-out of Medicare, this shift could alternatively increase beneficiary out-of-pocket spending.
From the perspective of the Medicare’s program integrity, Medicare would have significant difficulty tracking fraud and abuse if physicians were able to contract selectively for services with some but not all beneficiaries. Medicare would have to examine every physician-patient contract, on a claim-by-claim basis, to determine which claims could be reimbursed directly to the physician and which would be the full responsibility of the patient. Additionally, Medicare would need to examine these physicians’ billing practices to ensure that beneficiaries were not being charged inappropriately.
Conclusions
Balance billing limits, with incentives for physicians to accept assignment, have proven effective in limiting beneficiaries’ out-of-pocket liability for physician services. Today, a small share of Medicare beneficiaries experience balance billing just as only small share of provider claims in Medicare are paid unassigned—very different from the years before balance billing limits were instituted. Moreover, only about 1 percent of physicians provide services to beneficiaries on a private contracting basis. As the Congress has been considering changes to the way in which Medicare pays for physician service in the context of SGR repeal, some proposals have briefly surfaced to relax constraints on balance billing and private contracting.
On the one hand, these proposals could increase physician autonomy and provider willingness to treat Medicare patients, particularly among those providers who charge higher fees. On the other hand, such proposals could result in higher out-of-pocket liability, particularly in the longer term, which could affect beneficiary access to care. Additionally, relaxing these protections could foster less predictability in the fees beneficiaries encounter when seeing physicians and practitioners. Patients most at risk for experiencing a greater financial burden would be those with modest incomes and greater health care needs. Beneficiaries in geographic areas with limited choices of physicians might also be at higher risk if a growing number of providers choose to balance bill or require private contracts with their Medicare patients. The key is to strike a balance between assuring that providers receive fair payments from Medicare while also preserving financial protections that help beneficiaries face more predictable and affordable costs when they seek care.
Technical support in preparation of this brief was provided by Health Policy Alternatives, Inc.
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- Visualizing Health Policy: Physicians and Medicare
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Yearly "Wellness" visits
If you’ve had Medicare Part B (Medical Insurance) for longer than 12 months, you can get a yearly “Wellness” visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly “Wellness” visit isn’t a physical exam.
Your first yearly “Wellness” visit can’t take place within 12 months of your Part B enrollment or your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” preventive visit to qualify for a yearly “Wellness” visit.
Your costs in Original Medicare
You pay nothing for this visit if your doctor or other health care provider accepts assignment .
The Part B deductible doesn’t apply.
However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.
If Medicare doesn't cover the additional tests or services (like a routine physical exam), you may have to pay the full amount.
Your doctor or other health care provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your doctor develop a personalized prevention plan to help you stay healthy and get the most out of your visit. Your visit may include:
- Routine measurements (like height, weight, and blood pressure).
- A review of your medical and family history.
- A review of your current prescriptions.
- Personalized health advice.
- Advance care planning .
Your doctor or other health care provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease. Signs of cognitive impairment include trouble remembering, learning new things, concentrating, managing finances, and making decisions about your everyday life. If your doctor or other health care provider thinks you may have cognitive impairment, Medicare covers a separate visit to do a more thorough review of your cognitive function and check for conditions like dementia, depression, anxiety, or delirium and design a care plan.
If you have a current prescription for opioids, your doctor or other health care provider will review your potential risk factors for opioid use disorder, evaluate your severity of pain and current treatment plan, provide information on non-opioid treatment options, and may refer you to a specialist, if appropriate. Your doctor or other health care provider will also review your potential risk factors for substance use disorder, like alcohol and tobacco use , and refer you for treatment, if needed.
Related resources
- Preventive visits
- Social determinants of health risk assessment
Is my test, item, or service covered?
Costly Confusion: Medicare’s Wellness Visit Isn’t The Same As An Annual Physical
By Michelle Andrews March 20, 2019
Republish This Story
Disponible en Español
When Beverly Dunn called her new primary care doctor’s office last November to schedule an annual checkup, she assumed her Medicare coverage would pick up most of the tab.
The appointment seemed like a routine physical, and she was pleased that the doctor spent a lot of time with her.
Until she got the bill: $400.
Dunn, 69, called the doctor’s office assuming there was a billing error. But it was no mistake, she was told. Medicare does not cover an annual physical exam.
Dunn, of Austin, Texas, was tripped up by Medicare’s confusing coverage rules . Federal law prohibits the health care program from paying for annual physicals, and patients who get them may be on the hook for the entire amount. But beneficiaries pay nothing for an “annual wellness visit,” which the program covers in full as a preventive service.
“It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’” said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”
An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure.
The focus of the Medicare wellness visit is on preventing disease and disability by coming up with a “personalized prevention plan” for future medical issues based on the beneficiary’s health and risk factors.
At their first wellness visit, patients will often fill out a risk-assessment questionnaire and review their family and personal medical history with their doctor, a nurse practitioner or physician assistant. The clinician will typically create a schedule for the next decade of mammograms, colonoscopies and other screenings and evaluate people for cognitive problems and depression as well as their risk of falls and other safety issues.
They may also talk about advance care planning with beneficiaries to make decisions about what type of medical treatment they want in the future if they can’t make decisions for themselves.
At subsequent annual wellness visits, the doctor and patient will review these issues and check basic measurements. Beneficiaries can also receive other covered preventive services such as flu shots at those visits without charge.
When the Medicare program was established more than 50 years ago, its purpose was to cover the diagnosis and treatment of illness and injury in older people. Preventive services were generally not covered, and routine physical checkups were explicitly excluded, along with routine foot and dental care, eyeglasses and hearing aids.
Over the years, preventive services have gradually been added to the program, and the Affordable Care Act established coverage of the annual wellness visit. Medicare beneficiaries pay nothing as long as their doctor accepts Medicare.
However, if a wellness visit veers beyond the bounds of the specific covered preventive services into diagnosis or treatment — whether at the urging of the doctor or the patient — Medicare beneficiaries will typically owe a copay or other charges. (This can be an issue when people in private plans get preventive care, too. And it can affect patients of all ages. The ACA requires insurers to provide coverage, without a copay, for a range of preventive services, including immunizations. But if a visit goes beyond prevention, the patient may encounter charges.)
And to add more confusion, Medicare beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year of joining Medicare Part B, which covers physician services.
Meanwhile, some Medicare Advantage plans cover annual physicals for their members free of charge.
Many patients want their doctor to evaluate or treat chronic conditions like diabetes or arthritis at the wellness visit, said Dr. Michael Munger, who chairs the board of the American Academy of Family Physicians. But Medicare generally won’t cover lab work, such as cholesterol screening, unless it’s tied to a specific medical condition.
At Munger’s practice in Overland Park, Kan., staffers routinely ask patients who come in for a wellness visit to sign an “advance beneficiary notice of noncoverage” acknowledging that they understand Medicare may not pay for some of the services they receive.
As long as beneficiaries understand the coverage rules, it’s not generally a problem, Munger said.
“They don’t want to come back for a separate visit, so they just understand that there may be extra charges,” he said.
Beneficiaries may not be the only ones who are unclear about what an annual wellness visit involves, said Munger. Providers may be put off if they think that it’s just another task that adds to their paperwork.
A recent study published in the journal Health Affairs found that in 2015 just over half of practices with eligible Medicare patients didn’t offer the annual wellness visit. That year, 18.8 percent of eligible beneficiaries received an annual wellness visit, the analysis found.
Primary care physicians generally want to see their patients at least once a year, Munger said, but it needn’t be for a complete physical exam.
A wellness visit or even a visit for a sprained ankle could give doctors an opportunity to check in with patients and make sure they’re on track with preventive and other care, Munger said.
When Dunn called the doctor’s office about the $400 bill, she said, the staff told her she had signed papers agreeing to pay whatever Medicare didn’t cover.
Dunn doesn’t dispute that.
“There were lots of papers that I signed,” she said. “But nobody told me I would get a bill for $400. I would remember that.”
In the end, the clinic waived all but $100 of the charge, but warned her that next year she’ll have to pay $300 if she wants an annual physical with that doctor. If she comes in just for an annual wellness visit, she’ll be seen by a physician assistant.
Dunn is considering her options. She would like to stay with her new doctor, who came highly recommended, and she’s worried she might have trouble finding another one just as good who accepts Medicare. But $300 seems steep to her for a checkup.
“This whole thing was so stressful for me,” she said. “I lost sleep for nights. It’s not that I couldn’t afford it, but it didn’t seem right.”
Related Topics
Copy and paste to republish this story.
When Beverly Dunn called her new primary care doctor’s office last November to schedule an annual checkup, she assumed her Medicare coverage would pick up most of the tab.
Dunn, 69, called the doctor’s office assuming there was a billing error. But it was no mistake, she was told. Medicare does not cover an annual physical exam.
Dunn, of Austin, Texas, was tripped up by Medicare’s confusing coverage rules . Federal law prohibits the health care program from paying for annual physicals, and patients who get them may be on the hook for the entire amount. But beneficiaries pay nothing for an “annual wellness visit,” which the program covers in full as a preventive service.
“It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’” said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”
An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure.
The focus of the Medicare wellness visit is on preventing disease and disability by coming up with a “personalized prevention plan” for future medical issues based on the beneficiary’s health and risk factors.
They may also talk about advance care planning with beneficiaries to make decisions about what type of medical treatment they want in the future if they can’t make decisions for themselves.
And to add more confusion, Medicare beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year of joining Medicare Part B, which covers physician services.
Many patients want their doctor to evaluate or treat chronic conditions like diabetes or arthritis at the wellness visit, said Dr. Michael Munger, who chairs the board of the American Academy of Family Physicians. But Medicare generally won’t cover lab work, such as cholesterol screening, unless it’s tied to a specific medical condition.
At Munger’s practice in Overland Park, Kan., staffers routinely ask patients who come in for a wellness visit to sign an “advance beneficiary notice of noncoverage” acknowledging that they understand Medicare may not pay for some of the services they receive.
As long as beneficiaries understand the coverage rules, it’s not generally a problem, Munger said.
“They don’t want to come back for a separate visit, so they just understand that there may be extra charges,” he said.
Beneficiaries may not be the only ones who are unclear about what an annual wellness visit involves, said Munger. Providers may be put off if they think that it’s just another task that adds to their paperwork.
A recent study published in the journal Health Affairs found that in 2015 just over half of practices with eligible Medicare patients didn’t offer the annual wellness visit. That year, 18.8 percent of eligible beneficiaries received an annual wellness visit, the analysis found.
Primary care physicians generally want to see their patients at least once a year, Munger said, but it needn’t be for a complete physical exam.
A wellness visit or even a visit for a sprained ankle could give doctors an opportunity to check in with patients and make sure they’re on track with preventive and other care, Munger said.
When Dunn called the doctor’s office about the $400 bill, she said, the staff told her she had signed papers agreeing to pay whatever Medicare didn’t cover.
Dunn doesn’t dispute that.
“There were lots of papers that I signed,” she said. “But nobody told me I would get a bill for $400. I would remember that.”
In the end, the clinic waived all but $100 of the charge, but warned her that next year she’ll have to pay $300 if she wants an annual physical with that doctor. If she comes in just for an annual wellness visit, she’ll be seen by a physician assistant.
Dunn is considering her options. She would like to stay with her new doctor, who came highly recommended, and she’s worried she might have trouble finding another one just as good who accepts Medicare. But $300 seems steep to her for a checkup.
“This whole thing was so stressful for me,” she said. “I lost sleep for nights. It’s not that I couldn’t afford it, but it didn’t seem right.”
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Doctor Visits
Get Your Medicare Wellness Visit Every Year
Take Action
If you have Medicare, be sure to schedule a yearly wellness visit with your doctor or nurse. A yearly wellness visit is a great way to help you stay healthy.
What happens during a yearly wellness visit?
First, the doctor or nurse will ask you to fill out a questionnaire called a health risk assessment. Answering these questions will help you get the most from your yearly wellness visit.
During your visit, the doctor or nurse will:
- Go over your health risk assessment with you
- Measure your height and weight and check your blood pressure
- Ask about your health history and conditions that run in your family
- Ask about other doctors you see and any medicines you take
- Give advice to help you prevent disease, improve your health, and stay well
- Look for any changes in your ability to think, learn, or remember
- Ask about any risk factors for substance use disorder and talk with you about treatment options, if needed
If you take opioids to treat pain, the doctor or nurse may talk with you about your risk factors for opioid use disorder, review your treatment plan, and tell you about non-opioid treatment options. They may also refer you to a specialist.
Finally, the doctor or nurse may give you a short, written plan to take home. This plan will include any screening tests and other preventive services that you’ll need in the next several years. Preventive services are health care services that keep you from getting sick.
Learn more about yearly wellness visits .
Plan Your Visit
When can i go for a yearly wellness visit.
You can start getting Medicare wellness visits after you’ve had Medicare Part B for at least 12 months. Keep in mind you’ll need to wait 12 months in between Medicare wellness visits.
Do I need to have a “Welcome to Medicare” visit first?
You don’t need to have a “Welcome to Medicare” preventive visit before getting a yearly wellness visit.
If you choose to get the “Welcome to Medicare” visit during the first 12 months you have Medicare Part B, you’ll have to wait 12 months before you can get your first yearly wellness visit.
Learn more about the “Welcome to Medicare” visit .
What about cost?
With Medicare Part B, you can get a wellness visit once a year at no cost to you. Check to make sure the doctor or nurse accepts Medicare when you schedule your appointment.
If you get any tests or services that aren’t included in the yearly wellness visit (like an extra blood test), you may have to pay some of those costs.
Who Can Get Medicare?
Medicare is a federal health insurance program. You may be able to get Medicare if you:
- Are age 65 or older
- Are under age 65 and have a disability
- Have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease
- Have permanent kidney failure (called end-stage renal disease)
You must be living in the United States legally for at least 5 years to qualify for Medicare. Answer these questions to find out when you can sign up for Medicare .
Make an Appointment
Take these steps to help you get the most out of your Medicare yearly wellness visit.
Schedule your Medicare yearly wellness visit.
Call your doctor’s office and ask to schedule your Medicare yearly wellness visit. Make sure it’s been at least 12 months since your last wellness visit.
If you're looking for a new doctor, check out these tips on choosing a doctor you can trust .
To find a doctor who accepts Medicare:
- Search for a doctor on the Medicare website
- Call 1-800-MEDICARE (1-800-633-4227)
- If you use a TTY, call Medicare at 1-877-486-2048
Gather important information.
Take any medical records or information you have to the appointment. Make sure you have important information like:
- The name and phone number of a friend or relative to call if there’s an emergency
- Dates and results of checkups and screening tests
- A list of vaccines (shots) you’ve gotten and the dates you got them
- Medicines you take (including over-the-counter medicines and vitamins), how much you take, and why you take them
- Phone numbers and addresses of other places you go to for health care, including your pharmacy
Make a list of any important changes in your life or health.
Your doctor or nurse will want to know about any big changes since your last visit. For example, write down things like:
- Losing your job
- A death in the family
- A serious illness or injury
- A change in your living situation
Know your family health history.
Your family's health history is an important part of your personal health record. Use this family health history tool to keep track of conditions that run in your family. Take this information to your yearly wellness visit.
Ask Questions
Make a list of questions you want to ask the doctor..
This visit is a great time to ask the doctor or nurse any questions about:
- A health condition
- Changes in sleeping or eating habits
- Pain or discomfort
- Prescription medicines, over-the-counter medicines, or supplements
Some important questions include:
- Do I need to get any vaccines to protect my health?
- How can I get more physical activity?
- Am I at a healthy weight?
- Do I need to make any changes to my eating habits?
Use this question builder tool to make a list of things to ask your doctor or nurse.
It can be helpful to write down the answers so you remember them later. You may also want to take a friend or relative with you for support — they can take notes, too.
What to Expect
Know what to expect at your visit..
The doctor or nurse will ask you questions about your health and safety, like:
- Do you have stairs in your home?
- What do you do to stay active?
- Have you lost interest in doing things you usually enjoy?
- Do you have a hard time hearing people on the phone?
- What medicines, vitamins, or supplements do you take regularly?
The doctor or nurse will also do things like:
- Measure your height and weight
- Check your blood pressure
- Ask about your medical and family history
Make a wellness plan with your doctor.
During the yearly wellness visit, the doctor or nurse may give you a short, written plan — like a checklist — to take home with you. This written plan will include a list of preventive services that you’ll need over the next 5 to 10 years.
Your plan may include:
- Getting important screenings for cancer or other diseases
- Making healthy changes, like getting more physical activity
Follow up after your visit.
During your yearly wellness visit, the doctor or nurse may recommend that you see a specialist or get certain tests. Try to schedule these follow-up appointments before you leave your wellness visit.
If that’s not possible, put a reminder note on your calendar to schedule your follow-up appointments.
Add any new health information to your personal health documents.
Make your next wellness visit easier by updating your medical information in the personal health documents you keep at home. Write down any vaccines you got and the results of any screening tests.
Medicare offers an online tool called MyMedicare to help you track your personal health information and Medicare claims. If you have your Medicare number, you can sign up for your MyMedicare account now .
Healthy Habits
Take care of yourself all year long..
After your visit, follow the plan you made with your doctor or nurse to stay healthy. Your plan may include:
- Getting important screenings
- Getting vaccines for older adults
- Keeping your heart healthy
- Preventing type 2 diabetes
- Lowering your risk of falling
Your plan could also include:
- Getting active
- Eating healthy
- Quitting smoking
- Watching your weight
Content last updated February 9, 2023
Reviewer Information
This information on Medicare wellness visits was adapted from materials from the Centers for Medicare and Medicaid Services
Reviewed by: Rachel Katonak Centers for Medicare and Medicaid Services Division of Policy and Evidence Review Coverage and Analysis Group
November 2022
You may also be interested in:
Healthy Eating: Conversation Starters
Protect Your Health as You Grow Older
Depression: Conversation Starters
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Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website's privacy policy when you follow the link.
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When New Hires Get Paid More, Top Performers Resign First
- Andrea Derler,
- Peter Bamberger,
- Manda Winlaw,
- Cuthbert Chow
Research shows that unaddressed pay gaps will push veteran talent to find new jobs.
To attract new talent, employers often offer new hires higher wages than existing employees. But today, a combination of regulatory changes and technological advances have dramatically increased pay transparency in many sectors, making employees increasingly aware of these pay disparities. How do existing employees (and especially top performers) react to these higher-paid new hires? And how can organizations mitigate the associated risks? The authors’ recent research shows that unless employers adjust existing employees’ wages soon after making a new hire, employees tend to resign — and that top performers tend to resign faster than others. As such, employers should be aware of the impact hiring higher-paid external talent can have on their teams, conduct regular pay equity analyses to ensure that any disparities are fully explainable, and develop the agility necessary to adjust wages as soon as any inequities are identified.
To attract top talent, employers often pay new hires more than they pay existing employees in equivalent roles. This isn’t new . But today, regulatory changes and technological advances have dramatically increased pay transparency in many sectors, making employees more aware of these pay disparities. Moreover, data from the U.S. Chamber of Commerce indicates that the workforce is expected to shrink in 2024, while a global survey of more than 30,000 employees found that salaries are expected to increase by an average of 4% in 2024, suggesting that these pay gaps will likely continue to expand.
- AD Andrea Derler is Visier’s principal of research and value, where she collaborates with Visier’s team of data scientists, people analytics experts, as well as HR professionals to help produce practical, data-driven insights for organizations. Visier is a Canadian-based people analytics technology provider, which maintains a database of more than 15 million employee records from over 15,000 companies globally.
- PB Peter Bamberger is a professor of organizational behavior and the head of the organizational behavior department at the Coller School of Management, Tel Aviv University. He is the former editor in chief of Academy of Management Discoveries and currently serves as the President-Elect of the Academy of Management, as well as the research director of the Smithers Institute of Cornell University’s ILR School. He is a world-leading expert on compensation strategy and pay communication. His work has been cited over 15,000 times.
- MW Manda Winlaw is a data science manager at Visier, contributing to research and developing data products for the Visier app. She has worked as a data scientist in a number of different fields and strongly believes in using data to drive better decisions for all people.
- CC Cuthbert Chow , MDS, BBA, and LLB, works in Visier’s publications focus area as a data scientist co-op. Cuthbert’s primary role is discovering novel and industry-relevant insights within Visier’s rich community data. Cuthbert holds a master’s in data science and bachelor’s in law and business.
Partner Center
Medicare Wellness Visits Back to MLN Print November 2023 Updates
What’s Changed?
- Added information about monthly chronic pain management and treatment services
- Added information about checking for cognitive impairment during annual wellness visits
- Added information about Social Determinants of Health Risk Assessments as an optional element of annual wellness visits
Quick Start
The Annual Wellness Visits video helps you understand these exams, as well as their purpose and claim submission requirements.
Medicare Physical Exam Coverage
Initial Preventive Physical Exam (IPPE)
Review of medical and social health history and preventive services education.
✔ New Medicare patients within 12 months of starting Part B coverage
✔ Patients pay nothing (if provider accepts assignment)
Annual Wellness Visit (AWV)
Visit to develop or update a personalized prevention plan and perform a health risk assessment.
✔ Covered once every 12 months
Routine Physical Exam
Exam performed without relationship to treatment or diagnosis of a specific illness, symptom, complaint, or injury.
✘ Medicare doesn’t cover a routine physical
✘ Patients pay 100% out-of-pocket
Together we can advance health equity and help eliminate health disparities for all minority and underserved groups. Find resources and more from the CMS Office of Minority Health :
- Health Equity Technical Assistance Program
- Disparities Impact Statement
Communication Avoids Confusion
As a health care provider, you may recommend that patients get services more often than we cover or that we don’t cover. If this happens, help patients understand they may have to pay some or all costs. Communication is key to ensuring patients understand why you’re recommending certain services and whether we cover them.
Initial Preventive Physical Exam
The initial preventive physical exam (IPPE), also known as the “Welcome to Medicare” preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it’s provided within the first 12 months after the patient’s Part B coverage starts.
1. Review the patient’s medical and social history
At a minimum, collect this information:
- Past medical and surgical history (illnesses, hospital stays, operations, allergies, injuries, and treatments)
- Current medications, supplements, and other substances the person may be using
- Family history (review the patient’s family and medical events, including hereditary conditions that place them at increased risk)
- Physical activities
- Social activities and engagement
- Alcohol, tobacco, and illegal drug use history
Learn information about Medicare’s substance use disorder (SUD) services coverage .
2. Review the patient’s potential depression risk factors
Depression risk factors include:
- Current or past experiences with depression
- Other mood disorders
Select from various standardized screening tools designed for this purpose and recognized by national professional medical organizations. APA’s Depression Assessment Instruments has more information.
3. Review the patient’s functional ability and safety level
Use direct patient observation, appropriate screening questions, or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the patient’s:
- Ability to perform activities of daily living (ADLs)
- Hearing impairment
- Home and community safety, including driving when appropriate
Medicare offers cognitive assessment and care plan services for patients who show signs of impairment.
- Height, weight, body mass index (BMI) (or waist circumference, if appropriate), blood pressure, balance, and gait
- Visual acuity screen
- Other factors deemed appropriate based on medical and social history and current clinical standards
5. End-of-life planning, upon patient agreement
End-of-life planning is verbal or written information you (their physician or practitioner) can offer the patient about:
- Their ability to prepare an advance directive in case an injury or illness prevents them from making their own health care decisions
- If you agree to follow their advance directive
- This includes psychiatric advance directives
6. Review current opioid prescriptions
For a patient with a current opioid prescription:
- Review any potential opioid use disorder (OUD) risk factors
- Evaluate their pain severity and current treatment plan
- Provide information about non-opiod treatment options
- Refer to a specialist, as appropriate
The HHS Pain Management Best Practices Inter-Agency Task Force Report has more information. Medicare now covers monthly chronic pain management and treatment services .
7. Screen for potential SUDs
Review the patient’s potential SUD risk factors, and as appropriate, refer them to treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .
8. Educate, counsel, and refer based on previous components
Based on the results of the review and evaluation services from the previous components, provide the patient with appropriate education, counseling, and referrals.
9. Educate, counsel, and refer for other preventive services
Include a brief written plan, like a checklist, for the patient to get:
- A once-in-a-lifetime screening electrocardiogram (ECG), as appropriate
- Appropriate screenings and other covered preventive services
Use these HCPCS codes to file IPPE and ECG screening claims:
Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
Electrocardiogram, routine ecg with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
Electrocardiogram, routine ecg with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
Federally qualified health center (fqhc) visit, ippe or awv; a fqhc visit that includes an initial preventive physical examination (ippe) or annual wellness visit (awv) and includes a typical bundle of medicare-covered services that would be furnished per diem to a patient receiving an ippe or awv
* Section 60.2 of the Medicare Claims Processing Manual, Chapter 9 has more information on how to bill HCPCS code G0468.
Report a diagnosis code when submitting IPPE claims. We don’t require you to use a specific IPPE diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.
Part B covers an IPPE when performed by a:
- Physician (doctor of medicine or osteopathy)
- Qualified non-physician practitioner (physician assistant, nurse practitioner, or certified clinical nurse specialist)
When you provide an IPPE and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.
CPT only copyright 2022 American Medical Association. All rights reserved.
IPPE Resources
- 42 CFR 410.16
- Section 30.6.1.1 of the Medicare Claims Processing Manual, Chapter 12
- Section 80 of the Medicare Claims Processing Manual, Chapter 18
- U.S. Preventive Services Task Force Recommendations
No. The IPPE isn’t a routine physical that some patients may get periodically from their physician or other qualified non-physician practitioner (NPP). The IPPE is an introduction to Medicare and covered benefits, and it focuses on health promotion, disease prevention, and detection to help patients stay well. We encourage providers to inform patients about the AWV during their IPPE. The Social Security Act explicitly prohibits Medicare coverage of routine physical exams.
No. The IPPE and AWV don’t include clinical lab tests, but you may make appropriate referrals for these tests as part of the IPPE or AWV.
No. We waive the coinsurance, copayment, and Part B deductible for the IPPE (HCPCS code G0402). Neither is waived for the screening electrocardiogram (ECG) (HCPCS codes G0403, G0404, or G0405).
A patient who hasn’t had an IPPE and whose Part B enrollment began in 2023 can get an IPPE in 2024 if it’s within 12 months of the patient’s Part B enrollment effective date.
We suggest providers check with their MAC for available options to verify patient eligibility. If you have questions, find your MAC’s website .
Annual Wellness Visit Health Risk Assessment
The annual wellness visit (AWV) includes a health risk assessment (HRA). View the HRA minimum elements summary below. A Framework for Patient-Centered Health Risk Assessments has more information, including a sample HRA.
Perform an HRA
- You or the patient can update the HRA before or during the AWV
- Consider the best way to communicate with underserved populations, people who speak different languages, people with varying health literacy, and people with disabilities
- Demographic data
- Health status self-assessment
- Psychosocial risks, including, but not limited to, depression, life satisfaction, stress, anger, loneliness or social isolation, pain, suicidality, and fatigue
- Behavioral risks, including, but not limited to, tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual health, motor vehicle safety (for example, seat belt use), and home safety
- Activities of daily living (ADLs), including dressing, feeding, toileting, and grooming; physical ambulation, including balance or fall risks and bathing; and instrumental ADLs (IADLs), including using the phone, housekeeping, laundry, transportation, shopping, managing medications, and handling finances
1. Establish the patient’s medical and family history
At a minimum, document:
- Medical events of the patient’s parents, siblings, and children, including hereditary conditions that place them at increased risk
- Use of, or exposure to, medications, supplements, and other substances the person may be using
2. Establish a current providers and suppliers list
Include current patient providers and suppliers that regularly provide medical care, including behavioral health care.
- Height, weight, body mass index (BMI) (or waist circumference, if appropriate), and blood pressure
- Other routine measurements deemed appropriate based on medical and family history
4. Detect any cognitive impairments the patient may have
Check for cognitive impairment as part of the first AWV.
Assess cognitive function by direct observation or reported observations from the patient, family, friends, caregivers, and others. Consider using brief cognitive tests, health disparities, chronic conditions, and other factors that contribute to increased cognitive impairment risk. Alzheimer’s and Related Dementia Resources for Professionals has more information.
5. Review the patient’s potential depression risk factors
6. Review the patient’s functional ability and level of safety
- Ability to perform ADLs
7. Establish an appropriate patient written screening schedule
Base the written screening schedule on the:
- Checklist for the next 5–10 years
- United States Preventive Services Task Force and Advisory Committee on Immunization Practices (ACIP) recommendations
- Patient’s HRA, health status and screening history, and age-appropriate preventive services we cover
8. Establish the patient’s list of risk factors and conditions
- A recommendation for primary, secondary, or tertiary interventions or report whether they’re underway
- Mental health conditions, including depression, substance use disorders , suicidality, and cognitive impairments
- IPPE risk factors or identified conditions
- Treatment options and associated risks and benefits
9. Provide personalized patient health advice and appropriate referrals to health education or preventive counseling services or programs
Include referrals to educational and counseling services or programs aimed at:
- Fall prevention
- Physical activity
- Tobacco-use cessation
- Social engagement
- Weight loss
10. Provide advance care planning (ACP) services at the patient’s discretion
ACP is a discussion between you and the patient about:
- Preparing an advance directive in case an injury or illness prevents them from making their own health care decisions
- Future care decisions they might need or want to make
- How they can let others know about their care preferences
- Caregiver identification
- Advance directive elements, which may involve completing standard forms
Advance directive is a general term that refers to various documents, like a living will, instruction directive, health care proxy, psychiatric advance directive, or health care power of attorney. It’s a document that appoints an agent or records a person’s wishes about their medical treatment at a future time when the individual can’t communicate for themselves. The Advance Care Planning fact sheet has more information.
We don’t limit how many times the patient can revisit the ACP during the year, but cost sharing applies outside the AWV.
11. Review current opioid prescriptions
- Review any potential OUD risk factors
- Provide information about non-opioid treatment options
12. Screen for potential SUDs
Review the patient’s potential SUD risk factors, and as appropriate, refer them for treatment. You can use a screening tool, but it’s not required. The National Institute on Drug Abuse has screening and assessment tools. Implementing Drug and Alcohol Screening in Primary Care is a helpful resource .
13. Social Determinants of Health (SDOH) Risk Assessment
Starting in 2024, Medicare includes an optional SDOH Risk Assessment as part of the AWV. This assessment must follow standardized, evidence-based practices and ensure communication aligns with the patient’s educational, developmental, and health literacy level, as well as being culturally and linguistically appropriate.
1. Review and update the HRA
2. Update the patient’s medical and family history
At a minimum, document updates to:
3. Update current providers and suppliers list
Include current patient providers and suppliers that regularly provide medical care, including those added because of the first AWV personalized prevention plan services (PPPS), and any behavioral health providers.
- Weight (or waist circumference, if appropriate) and blood pressure
5. Detect any cognitive impairments patients may have
Check for cognitive impairment as part of the subsequent AWV.
6. Update the patient’s written screening schedule
Base written screening schedule on the:
7. Update the patient’s list of risk factors and conditions
- Mental health conditions, including depression, substance use disorders , and cognitive impairments
- Risk factors or identified conditions
8. As necessary, provide and update patient PPPS, including personalized health advice and appropriate referrals to health education or preventive counseling services or programs
9. Provide advance care planning (ACP) services at the patient’s discretion
10. Review current opioid prescriptions
11. Screen for potential substance use disorders (SUDs)
12. Social Determinants of Health (SDOH) Risk Assessment
Preparing Eligible Patients for their AWV
Help eligible patients prepare for their AWV by encouraging them to bring this information to their appointment:
- Medical records, including immunization records
- Detailed family health history
- Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists
Use these HCPCS codes to file AWV claims:
Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
Report a diagnosis code when submitting AWV claims. We don’t require you to use a specific AWV diagnosis code, so you may choose any diagnosis code consistent with the patient’s exam.
Part B covers an AWV if performed by a:
- Medical professional (including health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals directly supervised by a physician
When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury or to improve the functioning of a malformed body part.
You can only bill G0438 or G0439 once in a 12-month period. G0438 is for the first AWV, and G0439 is for subsequent AWVs. Don’t bill G0438 or G0439 within 12 months of a previous G0402 (IPPE) billing for the same patient. We deny these claims with messages indicating the patient reached the benefit maximum for the time period.
Medicare telehealth includes HCPCS codes G0438 and G0439.
ACP is the face-to-face conversation between a physician (or other qualified health care professional) and a patient to discuss their health care wishes and medical treatment preferences if they become unable to communicate or make decisions about their care. At the patient’s discretion, you can provide the ACP during the AWV.
Use these CPT codes to file ACP claims as an optional AWV element:
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)
Report a diagnosis code when submitting an ACP claim as an optional AWV element. We don’t require you to use a specific ACP diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.
We waive both the Part B ACP coinsurance and deductible when it’s:
- Provided on the same day as the covered AWV
- Provided by the same provider as the covered AWV
- Billed with modifier 33 (Preventive Service)
- Billed on the same claim as the AWV
We waive the ACP deductible and coinsurance once per year when billed with the AWV. If we deny the AWV billed with ACP for exceeding the once-per-year limit, we’ll apply the ACP deductible and coinsurance .
We apply the deductible and coinsurance when you deliver the ACP outside the covered AWV. There are no limits on the number of times you can report ACP for a certain patient in a certain period. When billing this service multiple times, document changes in the patient’s health status or wishes about their end-of-life care.
SDOH is important in assessing patient histories; in assessing patient risk; and in guiding medical decision making, prevention, diagnosis, care, and treatment. In the CY 2024 Medicare Physician Fee Schedule final rule , we added a new SDOH Risk Assessment as an optional, additional element of the AWV. At both yours and the patient’s discretion, you may conduct the SDOH Risk Assessment during the AWV.
Use this HCPCS code to file SDOH Risk Assessment claims as an optional AWV element:
Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes
Report a diagnosis code when submitting an SDOH Risk Assessment claim as an optional AWV element. We don’t require you to use a specific SDOH Risk Assessment diagnosis code as an optional AWV element, so you may choose any diagnosis code consistent with a patient’s exam.
The implementation date for SDOH Risk Assessment claims is July 1, 2024. We waive both the Part B SDOH Risk Assessment coinsurance and deductible when it’s:
We waive the SDOH Risk Assessment deductible and coinsurance once per year when billed with the AWV.
If we deny the AWV billed with SDOH Risk Assessment for exceeding the once-per-year limit, we’ll apply the deductible and coinsurance. We also apply the deductible and coinsurance when you deliver the SDOH Risk Assessment outside the covered AWV.
AWV Resources
- 42 CFR 410.15
- Section 140 of the Medicare Claims Processing Manual, Chapter 18
No. The AWV isn’t a routine physical some patients may get periodically from their physician or other qualified NPP. We don’t cover routine physical exams.
No. We waive the coinsurance, copayment, and Part B deductible for the AWV.
We cover an AWV for all patients who’ve had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn’t have an IPPE or AWV within those past 12 months. We cover only 1 IPPE per patient per lifetime and 1 additional AWV every 12 months after the date of the patient’s last AWV (or IPPE). Check eligibility to find when a patient is eligible for their next preventive service.
Generally, you may provide other medically necessary services on the same date as an AWV. The deductible and coinsurance or copayment applies for these other medically necessary and reasonable services.
You have different options for accessing AWV eligibility information depending on where you practice. Check eligibility to find when a patient is eligible for their next preventive service. Find your MAC’s website if you have specific patient eligibility questions.
Know the Differences
An IPPE is a review of a patient’s medical and social health history and includes education about other preventive services .
- We cover 1 IPPE per lifetime for patients within the first 12 months after their Part B benefits eligibility date
- We pay IPPE costs if the provider accepts assignment
An AWV is a review of a patient’s personalized prevention plan of services and includes a health risk assessment.
- We cover an annual AWV for patients who aren’t within the first 12 months after their Part B benefits eligibility date
- We cover an annual AWV 12 months after the last AWV’s (or IPPE’s) date of service
- We pay AWV costs if the provider accepts assignment
A routine physical is an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
- We don’t cover routine physical exams, but the IPPE, AWV, or other Medicare benefits cover some routine physical elements
- Patients pay 100% out of pocket
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Cast of ‘The Waltons’ pay a visit to Central Texas
WOODWAY, Texas (KWTX) - Fans from all over are in the Waco-area this weekend for Walton Fest, a convention centered around the classic TV show “The Waltons.”
Karen Owens is in town from Alabama, hoping to cross visiting Magnolia off her bucket list. She has stage four breast cancer and just recently found out about Walton Fest.
”When my friend let me know the Waltons were going to be here, I told them that I already bought tickets,” Owens said. “We had to be here.”
At the convention she got to see some of her idols from the show that originally premiered in 1972.
”Only two of the children are not here, Jon Walmsley who played Jason isn’t here,” event organizer Jack Bishop said. “Richard Thomas who played John Walton Jr. isn’t here either.”
Each of the cast members who were there had their own booth, signing autographs and snapping photos with their fans.
”I played the third son,” actor Eric Scott said. “There were seven kids and I was Ben. Some people would say I was not the easiest one to be around.”
A line stretched around Tucker Hall as thousands waited to see all of the stars.
”This is my 5th event and I always bring my travel journal with me,” fan Jackie Strickland said. “I have them give me autographs if they’re available and I have them all sign my book.”
Like many others, Strickland grew up with “The Waltons” and got her kids into it as well.
“In these challenging times it’s a good time to watch the show and ask yourself how they did it back then,” Strickland said. “It gives you the life lesson that even though it’s hard you can push forward.”
It’s a convention bringing generations together, more than 50 years after the show’s original premiere.
“Come to Waco, go see The Waltons if you get a chance,” Owens from Alabama said.
Walton Fest continues on Sunday with a sold-out breakfast with cast at 9 a.m. at Tucker Hall. There are still tickets available for the meet-and-greet which runs from noon to 4 p.m.
Copyright 2024 KWTX. All rights reserved.
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IRS: San Diego area taxpayers impacted by severe storms, flooding qualify for tax relief; various deadlines postponed to June 17
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IR-2024-51, Feb. 27, 2024
WASHINGTON — The Internal Revenue Service announced today tax relief for individuals and businesses in parts of California affected by severe storms and flooding that began on Jan. 21.
These taxpayers now have until June 17, 2024, to file various federal individual and business tax returns and make tax payments.
The IRS is offering relief to any area designated by the Federal Emergency Management Agency (FEMA) . Currently, this includes San Diego County. Individuals and households that reside or have a business in this locality qualify for tax relief.
The same relief will be available to any other California localities added later to the disaster area. The current list of eligible localities is always available on the disaster relief page on IRS.gov.
Filing and payment relief
The tax relief postpones various tax filing and payment deadlines that occurred from Jan. 21, 2024, through June 17, 2024 (postponement period). As a result, affected individuals and businesses will have until June 17, 2024, to file returns and pay any taxes that were originally due during this period.
This means, for example, that the June 17, 2024, deadline will now apply to:
- Individual income tax returns and payments normally due on April 15, 2024.
- 2023 contributions to IRAs and health savings accounts for eligible taxpayers.
- 2024 estimated tax payments normally due on April 15, 2024.
- Quarterly payroll and excise tax returns normally due on Jan. 31 and April 30, 2024.
- Calendar-year partnership and S corporation returns normally due on March 15, 2024.
- Calendar-year corporation and fiduciary returns and payments normally due on April 15, 2024.
- Calendar-year tax-exempt organization returns normally due on May 15, 2024.
Also, penalties for failing to make payroll and excise tax deposits due on or after Jan. 21, 2024, and before Feb. 5, 2024, will be abated as long as the deposits were made by Feb. 5, 2024.
The IRS disaster relief page has details on other returns, payments and tax-related actions qualifying for relief during the postponement period.
The IRS automatically provides filing and penalty relief to any taxpayer with an IRS address of record located in the disaster area. These taxpayers do not need to contact the agency to get this relief.
It is possible an affected taxpayer may not have an IRS address of record located in the disaster area, for example, because they moved to the disaster area after filing their return. In these kinds of unique circumstances, the affected taxpayer could receive a late filing or late payment penalty notice from the IRS for the postponement period. The taxpayer should call the number on the notice to have the penalty abated.
In addition, the IRS will work with any taxpayer who lives outside the disaster area but whose records necessary to meet a deadline occurring during the postponement period are located in the affected area. Taxpayers qualifying for relief who live outside the disaster area need to contact the IRS at 866-562-5227 . This also includes workers assisting the relief activities who are affiliated with a recognized government or philanthropic organization.
Reminder about extensions
The IRS urges anyone who needs an additional tax-filing extension, beyond June 17, 2024, for their 2023 federal income tax return to request it electronically by April 15, 2024. Though a disaster-area taxpayer qualifies to request an extension between April 15, 2024, and June 17, 2024, a request filed during this period can only be submitted on paper. Whether requested electronically or on paper, the taxpayer will then have until Oct. 15, 2024, to file, though payments are still due on June 17, 2024. Visit IRS.gov/extensions for details.
Additional tax relief
Individuals and businesses in a federally declared disaster area who suffered uninsured or unreimbursed disaster-related losses can choose to claim them on either the return for the year the loss occurred (in this instance, the 2024 return normally filed next year), or the return for the prior year (2023, normally filed this year). Taxpayers have extra time – up to six months after the due date of the taxpayer’s federal income tax return for the disaster year (without regard to any extension of time to file) – to make the election. For individual taxpayers, this means Oct. 15, 2025. Be sure to write the FEMA declaration number – 4758-DR − on any return claiming a loss. See Publication 547, Casualties, Disasters, and Thefts, for details.
Qualified disaster relief payments are generally excluded from gross income. In general, this means that affected taxpayers can exclude from their gross income amounts received from a government agency for reasonable and necessary personal, family, living or funeral expenses, as well as for the repair or rehabilitation of their home, or for the repair or replacement of its contents. See Publication 525, Taxable and Nontaxable Income, for details.
Additional relief may be available to affected taxpayers who participate in a retirement plan or individual retirement arrangement (IRA). For example, a taxpayer may be eligible to take a special disaster distribution that would not be subject to the additional 10% early distribution tax and allows the taxpayer to spread the income over three years. Taxpayers may also be eligible to make a hardship withdrawal. Each plan or IRA has specific rules and guidance for their participants to follow.
The IRS may provide additional disaster relief in the future.
The tax relief is part of a coordinated federal response to the damage caused by these storms and is based on local damage assessments by FEMA. For information on disaster recovery, visit DisasterAssistance.gov .
Iowa’s Caitlin Clark breaks ‘Pistol’ Pete Maravich’s NCAA Division I scoring record
Two weeks after she broke the record for women, Caitlin Clark has become NCAA Division I basketball’s overall top scorer, period.
The Iowa Hawkeyes star went into Sunday’s game against the Ohio State Buckeyes needing 18 points to break “Pistol Pete” Maravich’s record of 3,667 career points, which stood for more than 50 years. And with a second-quarter free throw, she became the top-scoring player — man or woman — in NCAA basketball history.
By the time the final buzzer rang out in Sunday’s game — in which the Hawkeyes beat the Buckeyes 93-83 — Clark had scored 35 points.
Clark’s Sunday total sets the new NCAA scoring record at 3,685 points.
Following the free throw that broke the scoring record, Clark said the record wasn’t on her mind, “but then when they announced it and everybody screamed, that’s when I knew,” she said in an interview with Fox reporter Allison Williams.
Clark said in a postgame interview with Williams that her team “came out and dominated” against the Buckeyes.
“I’m just proud of our girls,” Clark said. “It was a fun, dominant win for us. I thought we played really well.”
Clark, in an interview during her Senior Night ceremony, said she is “very grateful” after starting her career at Iowa “playing in front of absolutely no one during COVID,” and “now it’s impossible to get a ticket to get in the door to our games.”
“I think the people that have made it the most special, obviously my teammates, my coaches,” Clark said. “But it isn’t what it is without all of you,” she continued, gesturing to the cheering crowds of fans.
“I mean that and I thank you,” Clark said. “This is special. I don’t know if you guys realize what you’re doing for women’s basketball and women’s sports in general, but you’re changing it. You’re helping us change it.”
“I’ve put on an Iowa jersey for four years,” Clark said, “but like Coach Bluder and Kate [Martin] said, there’s still so much more fun to have and we’re not done.”
Clark, 22, earned the women’s record Feb. 15 when she scored her first 8 points in a game against Michigan and passed Kelsey Plum’s 3,527 points in a career that ended in 2017. Clark went on that night to score a career-high 49 points.
“I’m just really grateful, honestly, to be able to be here and make so many of my dreams come true,” Clark said after the history-making game, which Iowa won, 106-89.
She put up 33 points against Minnesota on Wednesday to cement her place atop the all-time career points among women to play for major colleges. The record had been held by Kansas great Lynette Woodard, who scored 3,650 points. (Woodard played from 1977 to 1981, when women’s sports were governed by the Association for Intercollegiate Athletics for Women.)
Clark and Woodard had a chance to catch up and celebrate following Sunday’s game.
“It’s just a great time for women’s basketball,” Woodard said in an interview with Fox’s Williams following Clark’s new record.
“Caitlin is leading the way. As she was chipping away I said, ‘Records are made to be broken, but also, they’re made to be honored,’” Woodard said. “And because of her, my records are being honored.”
Woodard continued: “I came to this game knowing she had 18 points to get. I had 19, but I have no more playing time. So, hopefully I passed her the baton for her to go ahead and burst through that ceiling, and I’m so happy for her.”
The overall record comes on Clark’s final regular-season game as a college athlete . Though the 22-year-old senior has another year of eligibility, she announced earlier this week that she would enter the WNBA draft next month.
“It probably won’t hit me until a little bit later, but I’m just gonna enjoy with my family and my teammates and I’m just really thankful to be in this place,” Clark said when asked what emotions she was feeling ahead of her “official goodbye” to Hawkeye Nation.
Her final season has been full of big moments and big numbers: She’s averaging 32 points per game, but at least four times this season she has racked up 40 points. The 6-foot guard from West Des Moines is also averaging more than 8 assists per game, and she recently recorded the 1,000th assist of her college career, making her only the sixth woman in college basketball history to do so.
With the scoring record in hand, Clark is now doubtless looking to lead her team, 25-4, to a national title. Last year, they made a run to the NCAA title game, where they lost to LSU.
Maravich’s NCAA men's scoring record was 3,667 points, which he set playing for LSU from 1968 to 1970.
After college, Maravich went on to an NBA career in which he was a five-time All-Star. He played for the Atlanta Hawks and the then-New Orleans Jazz and for one season with the Boston Celtics.Maravich died in 1988 in Pasadena, California, at 40 years old.
Phil Helsel is a reporter for NBC News.
Rebecca Cohen is a breaking news reporter for NBC News.
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122k 6 99 201. Add a comment. 1. In terms of being "formal", I'd actually say "visit" sounds more formal than "pay a visit to". At the very least the former is more proper English, while the latter is more of a turn of phrase. As for "emphatic", the definition according to Google is "showing or giving emphasis; expressing something forcibly and ...
A preventive care visit is different from an office visit: The purpose of a preventive visit is to review your overall health, identify risks and find out how to stay healthy. Your plan covers 100% of a preventive visit when you see a doctor in your plan network.*. The purpose of an office visit is to discuss or get treated for a specific ...
The phrase "pay regular visits" is correct and usable in written English. You can use it when you want to describe someone regularly visiting a place, typically in the context of social visits. For example, "I try to pay regular visits to my grandparents so they don't feel lonely.". exact ( 18 )
How Much is a Doctor Visit Without Insurance? In 2016, the average cost of visiting a healthcare professional in the U.S. was $265. However, this average depends on the type of medical provider you are seeing and the type of appointment. For example, the average visit to a primary care provider costs $186, whereas a visit to a specialist costs ...
Understanding the cost of your doctor visit. In the fourth installment of this 4-part series on health care costs, we look at the different types of care to help you better understand what you'll need to pay. Understanding your health plan costs can help you choose the right coverage and budget for your health care spending.
The practice has to pay more for utilities and rent, and those costs show up in your bill. For example, Mayo Clinic's Patient Estimates tool quotes $846 for a 60-minute office visit in Jacksonville, Florida, but $605 for the same visit in Wisconsin.
This chart from debt.org compares the costs of different medical conditions for emergency room and urgent care visits. Urgent Care. According to Debt.org, the average urgent care visit costs between $100 and $150 with insurance and up to $400 or $500 without insurance.. Nearly all procedures are covered by insurance, and urgent care centers typically have most of the equipment necessary to ...
In 2024, the annual deductible was $240. Once you've met the deductible, Medicare covers 80% of the Medicare-approved costs of the visit. Beneficiaries are responsible for the other 20%. Medicare also covers 80% of the Medicare-approved cost for preventive doctor visits. This is paid, even if the annual deductible hasn't been met.
Key takeaways: The cost of a telehealth visit will depend on several factors, such as your insurance, the condition, and the provider. On average, you could pay anywhere between $40 to $90 for a telehealth visit without insurance. You can save money on telehealth visits by checking your insurance coverage and asking about discounts.
Your annual deductible will need to be met before Medicare covers the full 80 percent of medically necessary doctor's visits. In 2020, the deductible for Part B is $198. This represents an ...
Medicare Part B covers your doctor visits, durable medical equipment, and medical services you receive in outpatient settings. You're responsible for the annual Part B deductible. Once that is met Medicare pays 80% of the Medicare-approved amount. This leaves you responsible for a 20% coinsurance and up to a 15% excess charge if your doctor ...
The difference between a physical exam and a Medicare Wellness Visit is basically the difference between your doctor focusing on what's wrong versus on what's right. Each is important, depending on the situation. When you're sick or in pain, you want to get better. A physical exam helps your doctor figure out what the problem is and what ...
Bill 99213 (or 99203 for new patients) with preventive or wellness code. An acute, uncomplicated illness at time of visit. An active, stable medical problem. Two minor problems. Remember to ...
In that case, the amount you would have to pay towards your deductible would be $1,050, not $2,000 . This isn't an issue if you're having a procedure that's many times more costly than your deductible. If you're about to have a knee replacement, which averages about $34,000, and your deductible is $5,000, you will have to pay the full deductible.
The annual wellness visit allows you to review your health history and identify any current or potential health risks with a health care professional. The visit enables the nurse to focus on prevention and wellness while making sure you are current on recommended immunizations and health screenings like colonoscopies or mammograms.
20 In these cases, providers require patients to pay them directly out-of-pocket, leaving the patient to seek reimbursement, if any, from their insurer. For providers with patients who have the ...
You pay nothing for the visit if your doctor or other health care provider accepts assignment .The Part B deductible doesn't apply.. However, you may have to pay coinsurance , and the Part B deductible may apply if your doctor or other health care provider performs additional tests or services during the same visit that Medicare doesn't cover under this preventive benefit.
for longer than 12 months, you can get a yearly "Wellness" visit to develop or update your personalized plan to help prevent disease or disability, based on your current health and risk factors. The yearly "Wellness" visit isn't a physical exam. Your first yearly "Wellness" visit can't take place within 12 months of your Part B ...
A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical ...
A wellness visit or even a visit for a sprained ankle could give doctors an opportunity to check in with patients and make sure they're on track with preventive and other care, Munger said. When Dunn called the doctor's office about the $400 bill, she said, the staff told her she had signed papers agreeing to pay whatever Medicare didn't ...
First, the doctor or nurse will ask you to fill out a questionnaire called a health risk assessment. Answering these questions will help you get the most from your yearly wellness visit. During your visit, the doctor or nurse will: Go over your health risk assessment with you. Measure your height and weight and check your blood pressure.
Same-day Preventive and E/M Services. Sometimes, at a scheduled preventive visit, the patient mentions a new or worsened condition. If the patient complaint requires additional workup, beyond that usually associated with the preventive service, you may choose to report a problem-focused visit in addition to the preventive service.
Moreover, data from the U.S. Chamber of Commerce indicates that the workforce is expected to shrink in 2024, while a global survey of more than 30,000 employees found that salaries are expected to ...
Initial Preventive Physical Exam. The initial preventive physical exam (IPPE), also known as the "Welcome to Medicare" preventive visit, promotes good health through disease prevention and detection. We pay for 1 IPPE per lifetime if it's provided within the first 12 months after the patient's Part B coverage starts. IPPE Components.
"Only two of the children are not here, Jon Walmsley who played Jason isn't here," event organizer Jack Bishop said. "Richard Thomas who played John Walton Jr. isn't here either."
President Biden on Monday will unveil his budget proposal for the coming fiscal year, calling for tax increases for large corporations and for billionaires to pay a minimum 25 percent tax rate. The…
Visit IRS.gov/extensions for details. Additional tax relief Individuals and businesses in a federally declared disaster area who suffered uninsured or unreimbursed disaster-related losses can choose to claim them on either the return for the year the loss occurred (in this instance, the 2024 return normally filed next year), or the return for ...
Judge denies Trump's request for more time to pay damages in Carroll defamation case. U.S. District Judge Lewis Kaplan said the former president has had plenty of time to arrange for payment since ...
March 1, 2024, 8:01 AM PST. By Adiel Kaplan. CVS Health, one of the nation's largest operators of retail chain pharmacies, will pay Ohio $1.5 million in penalties for problems largely related to ...
By the time the final buzzer rang out in Sunday's game — in which the Hawkeyes beat the Buckeyes 93-83 — Clark had scored 35 points. Clark's Sunday total sets the new NCAA scoring record ...