Medicare "once every 12 mos." Meaning?

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kaneohe

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You can get a Wellness visit and some other Medicare visits "once every 12 mos." What is the exact meaning of that phrase and do you have an official link that shows that? If you violate that rule (whatever it means) , Medicare will not cover it so it is useful to know exactly what it means.

More specifically, if the last visit was last yr Oct 15, what is the earliest I can do it this yr? Same question if last yr was Oct 2 or Oct 29.

Mainly interested in the timing issue, not the Wellness visit.
 
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Our doctor does a 'Wellness exam'. He has a long list of questions, orders the same test he use to, and Medicare pays. I use to go in once a year to 'update' prescriptions. Not as many questions, same blood test. Medicare paid.
 
Under the Medicare 12 month rule you cannot repeat a test for exactly 12 months and have Medicare pay for it. For example, I had a Mammogram on August 10 2019 and Medicare paid. I had to wait to get another Mammogram until August 11, 2020--otherwise Medicare would not pay. These rules are on the Medicare website.

I have found the Medicare Wellness visit to be worthless and a waste of time. I did not even get to see the doctor--one of his assistants just asked me some questions.
 
It's hard to know the context, as it could be encouraging people to go every 12 months telling them it's 100% covered, so people will actually go instead of once every 5 yrs or more.
I had a cousin who didn't see a doc for 10 yrs.

If you are sick or injured I would think they cover a visit partially at least.
 
Medicare "once every 12 mos." Meaning?

Just had my first Medicare wellness exam 3 days ago. Bloodwork, ekg, prostate exam. Also some shots / vaccines, but I didn’t get any on this trip. Cognitive test. And the dr asked a lot of questions that are canned for the Medicare exam.

And Medicare covers this once a year.

It is probably worth taking in my case. Ekg discovered an anomaly that they are going to check further in a stress test.

Timing may be critical in order for Medicare to cover things. The dr wouldn’t do one of the shots because I was 3 days shy of 65.
 
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The purpose of the wellness exam seems to be to document one's descent into senility. :LOL:
 
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harllee said:
Under the Medicare 12 month rule you cannot repeat a test for exactly 12 months and have Medicare pay for it. For example, I had a Mammogram on August 10 2019 and Medicare paid. I had to wait to get another Mammogram until August 11, 2020--otherwise Medicare would not pay. These rules are on the Medicare website.

..................................................
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Do you have a link to those rules? I am not able to find them anywhere.

This is what I believe the "once every 12 mos. rule" to be ........so far supported by empirical evidence of my visits and Medicare payment.
If your previous visit was in August last yr, your next visit can be anytime in August this yr and be covered even if the date is earlier. So if previous visit was Aug 15 (or Aug 2 or Aug 29), you can go this yr Aug 1 and be covered. However if previous visit was Aug 1 last yr, you cannot go July 31 this yr and be covered.

However I have not been able to find this specifically spelled out this way in print.............this is the closest so far https://www.englishforums.com/English/WhatDoesOnceMonthsMean/qvqqp/post.htm which mirrors my real life experience.
 
I think I have it figured out for me. Once a year a quick visit, draw blood, renew BP med. Now, on other hand....DW. She seems to be able to get bone densities every other, mammograms I think every other. But bloodwork? No can do. We just checked and it's been over two years since she's been stuck. The Gyn who takes care of all the other stuff USED to do annual bloodwork but says Medicare won't pay for him to order that, she has to go to a PCP. Well, she hasn't had one for several years. So we're in search of one. Makes no sense to me.

On my latest, a virtual, went for bloodwork afterwards. For some reason (I had no complaints) he ordered B-12 and D3 analysis. Get internet message I'm to report for a b-12 shot and start three months of weekly D3 pill, 50,000 units. That b-12 shot made me feel 10 years younger and lifted a lot of brain fog/anxiety that I really had just accepted as part of aging. Think I'll be getting a B-12 monthly for a year and then re-evaluate. Yes please.
 
kaneohe said:
Do you have a link to those rules? I am not able to find them anywhere.

This is what I believe the "once every 12 mos. rule" to be ........so far supported by empirical evidence of my visits and Medicare payment.
If your previous visit was in August last yr, your next visit can be anytime in August this yr and be covered even if the date is earlier. So if previous visit was Aug 15 (or Aug 2 or Aug 29), you can go this yr Aug 1 and be covered. However if previous visit was Aug 1 last yr, you cannot go July 31 this yr and be covered.

However I have not been able to find this specifically spelled out this way in print.............this is the closest so far https://www.englishforums.com/English/WhatDoesOnceMonthsMean/qvqqp/post.htm which mirrors my real life experience.
Click to expand...

Just google how often does Medicare pay for a wellness visit (or whatever test) and it will take you to the Medicare site. It says it only pays for one wellness visit or mammogram or whatever ever 12 months. If my Mammogram was August 12 2019 and I go to get another Mammogram on August 1 it will not be covered. My Mammogram will not be covered until August 13. Call Medicare if you need more clarification, I have found them very helpful.
 
kaneohe said:
Do you have a link to those rules? I am not able to find them anywhere.

This is what I believe the "once every 12 mos. rule" to be ........so far supported by empirical evidence of my visits and Medicare payment.
If your previous visit was in August last yr, your next visit can be anytime in August this yr and be covered even if the date is earlier. So if previous visit was Aug 15 (or Aug 2 or Aug 29), you can go this yr Aug 1 and be covered. However if previous visit was Aug 1 last yr, you cannot go July 31 this yr and be covered.

However I have not been able to find this specifically spelled out this way in print.............this is the closest so far https://www.englishforums.com/English/WhatDoesOnceMonthsMean/qvqqp/post.htm which mirrors my real life experience.
Click to expand...

Call Medicare--they will explain all this-- I have found them to be helpful. It is also on the Medicare website. For the wellness visit and other tests they will pay only every 12 months. If your wellness visit was August 12, 2019, they will not pay August 1, 2020. You have to wait until at least August 13, 2020 for them to pay.
 
Yeah, Pops flunked his exam. Said Bush was pres when it was Obama.
 
RobbieB said:
Yeah, Pops flunked his exam. Said Bush was pres when it was Obama.
Click to expand...
I could have fun with that statement but I'd be sent to the timeout room....:)
 
harllee said:
Call Medicare--they will explain all this-- I have found them to be helpful. It is also on the Medicare website. For the wellness visit and other tests they will pay only every 12 months. If your wellness visit was August 12, 2019, they will not pay August 1, 2020. You have to wait until at least August 13, 2020 for them to pay.
Click to expand...

Thanks for your reply. Yes , I know "every 12 mos." is on the website but the real meaning is not given in those words. I agree that Medicare is helpful (and you don't have to wait a lifetime like for SS). I got my interpretation from them some time ago and DW who doubted me got the same explanation yesterday. However, you know how verbal answers from CSRs can vary......that's why a link to a trusted source would be more valuable.

As I mentioned, I have empirical evidence from past visits that my interpretation might be right........have gone earlier in the month in later yrs.
and Medicare still paid..........have to stay in the same month though.

In your case, I would guess you have evidence that Medicare pays if you go later in the month the next yr.........but no evidence that it doesn't pay if you go earlier.
 
kaneohe said:
Thanks for your reply. Yes , I know "every 12 mos." is on the website but the real meaning is not given in those words. I agree that Medicare is helpful (and you don't have to wait a lifetime like for SS). I got my interpretation from them some time ago and DW who doubted me got the same explanation yesterday. However, you know how verbal answers from CSRs can vary......that's why a link to a trusted source would be more valuable.

As I mentioned, I have empirical evidence from past visits that my interpretation might be right........have gone earlier in the month in later yrs.
and Medicare still paid..........have to stay in the same month though.

In your case, I would guess you have evidence that Medicare pays if you go later in the month the next yr.........but no evidence that it doesn't pay if you go earlier.
Click to expand...

Where I go for my Mammogram would not let me make an appointment for August 12, 2020 because my last years appointment was August 14, 2019 and they said I had to wait until at least August 15 2020 or Medicare would not pay.
That was good enough for me.
 
harllee said:
Where I go for my Mammogram would not let me make an appointment for August 12, 2020 because my last years appointment was August 14, 2019 and they said I had to wait until at least August 15 2020 or Medicare would not pay.
That was good enough for me.
Click to expand...

If you're happy, no problem. As that link I posted said, the poster got different answers even from Medicare........so it would not be surprising if the appt desks of the medical centers have the same issue.......esp. since some non-Medicare medical plans are designed that way......each visit cannot be earlier than the previous yr.

In my case, I like to bundle my wellness exam and flu shot in the same visit to save a trip so it is an issue (for the wellness exam). I like what the Medicare rule apparently is since I cannot always get an appt when I want and if it were not designed that way, I would be pushed later and later every yr. The way it appears to be working now, at least I can stay in the same month.

........ but I would feel much better if I could find that rule and its interpretation in print. That's why I'm asking..............
 
kaneohe said:
........so it would not be surprising if the appt desks of the medical centers have the same issue.......esp. since some non-Medicare medical plans are designed that way......each visit cannot be earlier than the previous yr.


I ran into that years ago at my Ophthalmologist using employer insurance. Not one day earlier than 12 months!



In my case, I like to bundle my wellness exam and flu shot in the same visit to save a trip so it is an issue (for the wellness exam). I like what the Medicare rule apparently is since I cannot always get an appt when I want and if it were not designed that way, I would be pushed later and later every yr. The way it appears to be working now, at least I can stay in the same month.

........ but I would feel much better if I could find that rule and its interpretation in print. That's why I'm asking..............
Click to expand...


Keep asking! I'm interested, as it will set when I can get a flu shot.
 
Telly said:
Keep asking! I'm interested, as it will set when I can get a flu shot.
Click to expand...

You should verify but flu shots appear to be different. Instead of the ambiguous "once every 12 mos", flu shots are once per flu season .......you'd have to find out when the new season begins.......have a feeling it's Sept.
https://www.medicare.gov/coverage/flu-shots

"Flu shots
Medicare Part B (Medical Insurance) covers one flu shot per flu season.
Your costs in Original Medicare
You pay nothing for a flu shot if your doctor or other qualified health care provider accepts assignment for giving the shot."
 
I found it!..........a semi-official definition/explanation from CMS
(it's the very last question)

https://www.cms.gov/Outreach-and-Ed...N/MLNProducts/downloads/IPPE_AWVQuestions.pdf

"20) Can you clarify the exact timeframe between Annual Wellness Visits (AWVs)? Is it 365 days from the date of the last AWV or 11 months, etc.?
Annual Wellness Visits (AWVs) are covered by Medicare at 12 month intervals. This means that 11 full calendar months must pass after the month in which a beneficiary had received an AWV. Under this method of counting, a beneficiary could receive an AWV at the end of a given month, for example, January 2011, then in the following January 2012, the beneficiary would be eligible for an AWV
in the beginning of that month. Therefore 365 days would not need to elapse between visits, provided that 11 full months had passed since the last visit"

and yet despite this seemingly definitive document , there is this caution
https://www.physicianspractice.com/view/coding-wellness-visits-and-time-based-statements
 
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Glad you found the answer. Here is the timeline for Mammography for those on original Medicare. With all the different insurance plans they have to deal with, some providers require 365 days to be sure they get it right for that patient.
Medicare Claims Processing Manual
Chapter 18 - Preventive and Screening Services
Section 20.A - Screening Mammography

Over age 39: Annual (11 full months have elapsed following the month of last screening).

NOTE: Count months between screening mammographies beginning the month after the date of the examination. For example, if Mrs. Smith received a screening mammography examination in January 2005, begin counting the next month (February 2005) until 11 months have elapsed. Payment can be made for another screening mammography in January 2006.

Reference: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c18.pdf
Click to expand...
 
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true confession time.............although I did independently find that link this AM after being unsuccessful yesterday........today I thought it was an important enough answer that I should save it for all time.

I put those links in an e-mail to myself and then went to file it in my Medicare folder. Guess what I found after I did that............I found another note (or rather notes) to myself less than a yr ago asking the same question . One of them (probably the first) was an ER thread which was answered by joeea and translated by cathy63 . So give those 2 credit for the first find.......even tho I couldn't google that up even citing the site. https://www.early-retirement.org/fo...hs-a-medicare-question-99813.html#post2294846
 
kaneohe said:
true confession time.............although I did independently find that link this AM after being unsuccessful yesterday........today I thought it was an important enough answer that I should save it for all time.

I put those links in an e-mail to myself and then went to file it in my Medicare folder. Guess what I found after I did that............I found another note (or rather notes) to myself less than a yr ago asking the same question . One of them (probably the first) was an ER thread which was answered by joeea and translated by cathy63 . So give those 2 credit for the first find.......even tho I couldn't google that up even citing the site. https://www.early-retirement.org/fo...hs-a-medicare-question-99813.html#post2294846
Click to expand...
That is why the doc tests you for senility as part of the "wellness" exam. ;)
 
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