Eight things Medicare won’t cover that you should know

Medicare is the federal health insurance program that covers most Americans age 65 and older and some younger people with disabilities.

It is divided into four main parts: Part A covers hospital stays and short-term skilled care; Part B covers outpatient care and certain preventive services; Part C, or Medicare Advantage, combines Parts A and B and may add extra benefits such as dental or vision coverage; and Part D covers prescription drugs. Each part has specific limits on what it will pay for, which is why many beneficiaries are surprised by gaps in coverage.

Despite its popularity, Medicare does not cover everything you might expect. Routine physicals, most dental and vision care, hearing aids, long-term custodial care, and certain diagnostic tests can result in out-of-pocket costs. Understanding what is not covered is just as important as knowing what is, because it helps you avoid unexpected bills and plan effectively for your health needs. The following eight exclusions are among the most common and important to know.

Medicare Annual Physical

Many people assume Medicare covers a traditional annual physical, as most private insurance plans do. In reality, Original Medicare (Parts A & B) does not cover routine physical exams in the way most people think of them, meaning a hands‑on checkup with labs, a full body exam, and preventive testing isn’t covered under traditional Medicare alone.

Instead, Medicare offers specific preventive benefits that are designed to detect risk and plan preventive care, but these differ substantially from a physical. The way a visit is coded by the doctor matters a lot: if it’s billed as a wellness visit, it’s covered, but if it’s billed as a routine physical, it may not be.

This distinction is the source of frequent billing surprises. Beneficiaries often receive unexpected bills because routine tests or services performed during a preventive visit aren’t always covered under that benefit.

Extra Tests During the Welcome to Medicare Visit Aren’t Covered

When you first enroll in Medicare Part B, you’re also entitled to a one‑time Welcome to Medicare preventive visit within the first 12 months. This is not a physical exam either, but it helps establish your health baseline and starts your prevention plan.

At both the Welcome and Annual Wellness visits, additional tests or services beyond preventive care, such as labs, imaging, or specialized screening, may incur costs. This distinction explains why people sometimes receive a bill even after what they thought was a free check‑up.

Routine Physicals

Medicare’s preventive services are designed based on evidence that continuous risk assessment and prevention planning reduce long‑term disease and disability more effectively than annual physicals alone. AWVs emphasize health history, risk factors, and preventive coaching rather than full diagnostic exams.

Routine physicals typically include diagnostic testing and hands‑on evaluations that Medicare considers diagnostic, not preventive, and they are covered only when medically necessary, not just because it’s annual.

That’s why, if you want traditional examinations with lab panels and a full physical, you often must pay out‑of‑pocket or have supplemental coverage that specifically includes those services.

Extra Diagnostic Services at a Wellness Visit

A common real‑world complication is that people combine a wellness visit with discussions about current symptoms or chronic issues. In billing terms, those parts may be coded as office visits or diagnostic services, and Medicare may charge copays and deductibles for those portions.

That’s why some doctors generate two claims for the same appointment: one for the preventive AWV (covered) and one for the office visit if anything beyond preventive risk assessment is addressed (billable to you).

Even Medicare Advantage May Not Cover Everything You Expect

If you’re in a Medicare Advantage (Part C) plan, the plan must cover everything Original Medicare does, including the Welcome and Annual Wellness visits.

Many Advantage plans go further and offer annual physical exams at no extra cost, or include additional benefits like labs, gym memberships, dental, and hearing. However, benefits vary widely by plan, so it’s essential to check your specific policy details.

Some Preventive Services Aren’t Covered

Even though traditional physicals aren’t covered, the emphasis on prevention has real value. Annual Wellness Visits help identify risk factors early, update your preventive care plan, and connect you to appropriate screenings (such as mammograms, colonoscopies, and bone density tests) that are covered by Medicare when indicated.

Annual wellness planning can improve long‑term health outcomes by promoting lifestyle changes, updating vaccinations, and coordinating chronic care.

Care Medicare Won’t Pay For If It’s Billed the ‘Wrong’ Way

One practical issue is that providers must use the correct Medicare billing codes for a wellness visit to be covered. If a visit is miscoded as a routine physical, Medicare may deny coverage, leaving you responsible for the bill.

This underscores the importance of clear communication with your doctor’s office about the type of appointment you’re scheduling and of ensuring they understand Medicare’s preventive benefit structure.

Coordinating Preventive and Diagnostic Care

You can still get diagnostic exams and lab work paid when medically necessary, but these must be separately justified and coded accordingly. If your doctor finds a significant issue during an AWV, they may order diagnostic tests or schedule a separate visit, which would be covered under Part B as usual, with applicable cost‑sharing.

Strategically planning the AWV and other necessary tests can minimize out‑of‑pocket costs. For example, scheduling labs on a different day or clarifying coverage before tests are ordered can help manage billing surprises.

What Medicare Does Cover: Annual Wellness Visits

Original Medicare Part B does cover a yearly Annual Wellness Visit (AWV) once every 12 months after you’ve had Part B for at least a year. This visit focuses on prevention and risk assessment, not physical diagnosis.

During the AWV, your provider will review your medical and family history, current prescriptions, routine measures like height, weight, and blood pressure, and perform a cognitive assessment if appropriate. A health risk questionnaire helps shape a personalized prevention plan.

If your provider accepts Medicare assignment, the AWV is covered at no cost; you won’t owe a copay or deductible for that visit alone.

Practical Tips for Beneficiaries

• Schedule your Annual Wellness Visit early each year.
• Call your doctor’s office beforehand to ensure they plan to bill the visit as an AWV.
• Bring a list of medications and health history to maximize the visit’s usefulness.
• Know what’s preventive vs. diagnostic.
• If you have a Medicare Advantage plan, review its additional benefits.
• Ask before getting extra services at your wellness visit to avoid surprise charges.

Key Takeaway

Medicare supports preventive care through Welcome and Annual Wellness Visits, but it does not pay for routine annual physicals under Original Medicare. Whether through Original Medicare or Advantage, understanding how preventive visits are structured and billed is key to avoiding unexpected bills and getting the preventive care you need.

Disclosure line: This article was written with the assistance of AI and was subsequently reviewed, revised, and approved by our editorial team.

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