Medicare is the federal health insurance program primarily serving individuals aged 65 or older, as well as certain younger people with specific disabilities or conditions. While the program assists with healthcare expenses, it does not cover all medical costs. Doctor visits are covered under Medicare, but the exact coverage and patient financial responsibilities depend on the specific plan chosen, such as Original Medicare (Parts A and B) or a Medicare Advantage Plan (Part C).
Coverage Through Original Medicare Part B
Original Medicare is the traditional fee-for-service plan administered by the federal government, consisting of Part A (Hospital Insurance) and Part B (Medical Insurance). Part B covers most physician visits and outpatient services deemed medically necessary for diagnosing or treating a health condition.
Part B covers visits to primary care doctors, specialists, and other healthcare professionals. It also covers certain preventive services, such as the “Welcome to Medicare” visit and the Annual Wellness Visit. Original Medicare generally does not cover a comprehensive annual physical exam.
For most covered services, Medicare Part B pays 80% of the Medicare-approved amount. The individual is responsible for the remaining 20% coinsurance after meeting an annual deductible. The structure of Original Medicare generally allows beneficiaries to see any doctor in the country who accepts Medicare.
Doctor Visits Under Medicare Advantage Plans
Medicare Advantage Plans (Part C) are an alternative way to receive Medicare benefits, administered by private insurance companies approved by Medicare. These plans must provide at least the same coverage as Original Medicare Parts A and B, including doctor visits. Part C plans often utilize managed care structures like Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs).
Instead of the 20% coinsurance structure of Original Medicare, Advantage plans usually use fixed dollar copayments for doctor visits. These plans often bundle in additional benefits not covered by Original Medicare, such as routine dental, vision, or hearing care.
HMOs and PPOs
HMO plans typically require members to receive care within a specific network of providers, except in urgent or emergency situations. Many HMOs also require a referral from a primary care physician to see a specialist. PPO plans offer more flexibility, allowing members to see out-of-network providers, usually at a higher cost, and generally do not require referrals for specialist visits.
Understanding Deductibles and Coinsurance
The financial responsibility for doctor visits varies between Original Medicare and Medicare Advantage, but both require the patient to cover some costs. For Original Medicare Part B, the patient must first satisfy an annual deductible before coverage begins.
Once the deductible is met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for most services, including physician visits. This 20% can accumulate rapidly. To mitigate this financial risk, many beneficiaries purchase Medicare Supplement Insurance (Medigap).
Medigap plans are standardized policies sold by private companies that help cover the out-of-pocket costs left by Original Medicare, primarily the Part B coinsurance. Nearly all Medigap plans cover the 20% Part B coinsurance for physician visits, significantly reducing the financial exposure of the beneficiary. Medicare Advantage plans replace the 20% coinsurance with fixed copayments and feature an annual out-of-pocket maximum, providing a ceiling on yearly medical expenses.
How Provider Acceptance Affects Your Visit
A doctor visit is only covered if the provider has a specific agreement with Medicare, and the nature of this agreement determines the patient’s final costs. Providers fall into three main categories regarding their relationship with Original Medicare. A Participating Provider agrees to accept “assignment,” meaning they accept the Medicare-approved amount as payment in full for covered services. These providers can only bill the patient for the deductible and the 20% coinsurance.
A Non-Participating Provider accepts Medicare but does not agree to accept assignment on all claims. While they must still submit claims to Medicare, they are legally permitted to charge the patient up to 15% more than the Medicare-approved amount, which is known as the “limiting charge.” The patient may be responsible for the 20% coinsurance plus the additional 15% charge.
The third category is the Opt-Out Provider, who has formally signed an agreement to be excluded from the Medicare program entirely. These providers do not bill Medicare for services, and the patient is responsible for 100% of the cost, as Medicare will not provide any reimbursement. Before receiving care, an Opt-Out Provider must have the patient sign a private contract acknowledging that Medicare coverage will not apply.