Medicare is a federal health insurance program intended for people who are 65 or older and certain younger people with disabilities. This system of coverage is divided into multiple parts, and the extent to which doctor visits are covered depends on which specific part a person is enrolled in. Understanding this structure is the first step in knowing what you will pay for routine or specialized medical appointments.
Coverage Under Original Medicare Part B
The direct answer to whether Medicare covers doctor visits is found in Original Medicare Part B, which is the component that covers medical services. Part B covers medically necessary services, which include visits to primary care doctors and specialists, outpatient care, and diagnostic testing. Medically necessary care is defined as services needed to diagnose or treat a health condition according to accepted standards of medical practice.
Part B also covers a range of preventive services, which are designed to keep a person healthy or to detect illness early. This includes the Annual Wellness Visit (AWV), which is distinct from a typical physical exam and involves creating or updating a personalized prevention plan. These covered services can include visits for mental health care, certain physical and occupational therapies, and durable medical equipment. The only limit is that the service must be provided by a doctor or other healthcare professional who accepts Medicare.
Understanding Cost-Sharing and Patient Responsibility
While Original Medicare Part B covers doctor visits, it does not pay for the entire cost, which leaves the patient with several financial responsibilities. The first is a monthly premium that must be paid to maintain Part B coverage. This premium can be higher for individuals with higher incomes, based on an income-related monthly adjustment amount.
After securing coverage, the annual Part B deductible must be met before Medicare begins to pay its share for most services. Once the deductible is satisfied, the patient is then responsible for a coinsurance amount, which is a percentage of the Medicare-approved charge for each service.
The patient’s coinsurance is typically 20% of the Medicare-approved amount, with Medicare paying the remaining 80%. This 20% share applies to most doctor visits, outpatient therapies, and medical equipment. However, certain preventive services, like the Annual Wellness Visit, are covered at 100% and are not subject to the deductible or coinsurance.
Variations with Medicare Advantage Plans
Medicare Advantage, also known as Part C, is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans must cover all the same medically necessary and preventive services as Original Medicare Part A and Part B, including doctor visits. However, Advantage plans structure the coverage and costs differently than the traditional program.
Most Medicare Advantage plans, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, use a network of providers. Patients typically pay lower costs when they see doctors and specialists who are in the plan’s network. Seeing an out-of-network provider may result in higher costs or, in some cases, no coverage at all, especially with HMOs.
Instead of the 20% coinsurance model of Part B, Medicare Advantage plans usually charge a fixed copayment for doctor visits. These plans may also require a referral from a primary care doctor to see a specialist, adding another layer to the process of accessing care.
The Importance of Doctor Acceptance
Coverage under Medicare does not automatically guarantee that every doctor will accept the patient’s insurance. To ensure the most predictable costs, patients should confirm that their doctor “Accepts Assignment”. When a doctor accepts assignment, they agree to accept the Medicare-approved amount as the total payment for the service.
A doctor who accepts assignment is prohibited from charging the patient more than the standard Part B deductible and 20% coinsurance. If a doctor participates in Medicare but does not accept assignment, they can charge the patient up to 15% more than the Medicare-approved amount. This extra amount, known as a balance bill or limiting charge, is an out-of-pocket cost the patient must cover.
If a doctor has “opted out” of Medicare entirely, they can charge whatever they wish, and Medicare will not provide any payment for the services received. Before scheduling an appointment, it is wise for patients to verify their doctor’s status to avoid unexpected balance billing.