Yes, Medicare covers doctor’s visits if they’re medically necessary. If you have Original Medicare, visits are covered by your Part B insurance. Costs can vary depending on the type of visit and whether or not your doctor accepts the Medicare-approved amount for payment. Knowing what Medicare does and doesn’t cover before your next visit can help you better plan your medical expenses.
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The Importance of Regular Checkups
The U.S. Preventive Services Task Force recommends that adults aged 65 see their doctors for a routine checkup regularly; at least once a year. Unfortunately, many people aren’t taking that advice, as 44% of people are overdue for a regular checkup.
During these checkups, a doctor can assess you for any emerging medical issues, identify your risk of future problems, and help you maintain a healthy lifestyle. A study on the impact of routine general screenings found that patients with regular health checks tend to have increased chronic disease recognition and treatment. They also received more preventive services and had better patient-reported outcomes.
What Types of Doctor Visits and Outpatient Services Does Medicare Cover?
Medicare covers many different kinds of doctor visits. You must have an underlying health condition or risk factor to be eligible for many of these services. Usually, Medicare pays for 80% of covered visits, meaning you pay the other 20%. Here’s a closer look at the types of doctor visits and outpatient services that Medicare typically covers.
Preventative Services
Preventive services help you catch health problems early on before they’re an issue. Medicare covers dozens of preventive and screening services if you have certain risk factors, including:
- Abdominal aortic aneurysm screenings
- Cardiovascular disease screenings
- Colorectal cancer screenings
- Diabetes screenings
- Flu and vaccine shots
- HIV screenings
- Nutrition therapy services
- Obesity screenings and counseling
Medicare also covers an annual wellness visit. This is a chance for your provider to take routine measurements, ask you about your family and medical history, and address any concerns you might have about your health. You may also receive a cognitive assessment to check for warning signs of dementia.
Medical Services
During a doctor’s visit, if your provider recommends you get a certain test or procedure, Medicare Part B might cover the bill. These services have to be medically necessary, meaning they’re needed to diagnose or treat a disease, condition, illness, or injury. They differ from preventive services because they’re done when a doctor suspects you have a certain condition or wants to treat you for a condition.
Some of the medical services that may be covered after your doctor’s recommendation include:
- Clinical laboratory tests
- Colonoscopies
- Dialysis services and supplies
- Fecal occult blood tests
- Opioid use disorder treatment services
- Prosthetic devices
- Sleep studies
- X-rays
Specialist Visits
Sometimes, you might need care from a specialist provider. Medicare offers coverage for these types of outpatient services as well. For example, if you need mental health care, your Part B benefits cover one depression screening per year, individual and group psychotherapy, and family counseling.
You may also be covered for other types of therapy, like physical therapy, occupational therapy, and speech-language pathology therapy, as long as your doctor prescribes it. Certain types of specialists, such as dentists, podiatrists, optometrists, or chiropractors, may be covered by Medicare if you have an underlying condition that requires treatment.
What Kinds of Doctor Visits Does Medicare Not Cover?
Medicare does not cover every type of doctor visit. For example, routine physical checkups are not covered unless you have a specific issue. Also, routine eye examinations and dental services usually aren’t covered. There are a few exceptions, like if you have an eye disease like glaucoma or need a tooth extraction to prepare for radiation treatment.
Other non-covered services include:
- Hearing aid examinations
- Chiropractor visits not involving manual manipulation of the spine
- Routine foot care
- Follow-up care after a hospital stay for a non-covered service
- Massage therapy
Wellness Visits
In contrast to physicals, Medicare recipients are entitled to an annual wellness visit. This is a yearly visit that is covered under Medicare Part B. During this visit, the doctor will review the patient’s medical history and current health status, check vital signs, and assess the patient’s risk factors for certain diseases.
The doctor will also develop a personalized prevention plan that includes recommendations for preventive screenings, vaccinations, and lifestyle changes.
How Medicare Covers Your Visits to the Doctor
Your Medicare Part B benefits cover your visits to the doctor. However, you must pay your annual deductible before your services or visits are covered. For 2023, this is $226. This isn’t an additional fee; it’s the amount you pay in covered medical bills before Medicare kicks in.
Medicare has an established rate it pays out for each covered service it offers. If a doctor agrees to this rate, it’s called accepting assignment. When you go to providers that accept assignment, the Medicare copay for doctor visits is 20%. Going to providers that accept assignment can mean lower out-of-pocket costs for you.
If your provider refuses to accept the Medicare-approved amount, they can charge up to 15% more. You would be responsible for paying this 15% difference.
In some cases, providers opt out of Medicare entirely. This means Medicare doesn’t pay anything toward a visit; you would have to pay 100% of the costs yourself. The exception is if you’re in an emergency.
How Medigap Coverage Helps
Medigap plans are add-on medical supplemental insurance that can help you pay for your Medicare copayments, coinsurance, and deductibles. You pay a monthly premium; in return, you might pay less on some of your medical bills.
A few plans can help you pay for doctor visit costs. Plan K can cover 50% of your Part B coinsurance, while Plan L can cover 75%. The following plans cover your Part B coinsurance at 100%:
Unfortunately, new Medigap plans no longer cover the Part B deductible, so you must pay that on your own.
How Medicare Advantage Covers Your Visits to the Doctor
Some people choose to enroll in a private Medicare plan called Medicare Advantage. Sometimes called Part C, Medicare Advantage plans are managed by private insurers and follow strict rules to ensure you get the same level of coverage as you would with Original Medicare.
However, many plans provide extra benefits. For example, some plans may include coverage for dental services, massage therapy, and chiropractor services.
Additionally, costs work differently with Part C plans. Each plan has its rules on your deductible, copayments, and coinsurance. However, one crucial difference is that these plans come with an out-of-pocket limit, the maximum amount you must pay in medical bills each year before your expenses are covered at 100%. Original Medicare doesn’t have an out-of-pocket max, meaning you keep paying copayments no matter what.
Medicare Coverage of Telehealth
Telehealth lets you receive medical services at your home through video or audio technology. For example, you might get on a video call with your doctor to ask about specific symptoms. Through telehealth, doctors can examine, diagnose, and treat you like they would at an in-person visit. If necessary, they can also prescribe medications.
Like in-person doctor visits, Medicare covers telehealth visits at 80% after you pay your Part B deductible. This means you pay 20% of the cost of each visit. However, this coverage is temporary until December 31, 2024. After that time, to be eligible to receive telehealth services, you must meet one or more of these criteria:
- Live in a rural area without easy access to healthcare
- Have monthly end-stage renal disease visits
- Need a diagnosis, evaluation, or treatment of symptoms from an acute stroke, mental health disorder, or substance use disorder
Medicare Coverage of Doctor-prescribed Medication
Original Medicare usually doesn’t cover prescription medication. There are a few exceptions if you have specific medical conditions, but for many people, an easy way to get medication coverage is with Part D.
Medicare Part D is an add-on plan that specifically covers the drugs your doctor prescribes. Private insurance companies manage these plans, so each differs. For example, every plan comes with a unique formulary; the list of prescription drugs it covers.
Another option is to enroll in a Medicare Advantage plan. These usually bundle prescription drug coverage, so you don’t need to deal with multiple plans. MA plans also bundle Medicare Part A and B benefits.
What Are Your Options If Medicare Does Not Cover a Doctor You Need?
It’s possible that Medicare might not offer coverage for a doctor you want to see. If that’s the case, you have several options at your disposal.
Ask for a Referral to Another Provider
One option is to ask your primary care provider for a referral to another in-network provider. Chances are, they have a good network of doctors to recommend based on your specific needs.
Pay the Costs Out of Pocket
If you really want to see a specific doctor, you can pay for your visit out of pocket. Sometimes, doctors are willing to negotiate lower rates for patients without insurance.
Switch to a Medicare Advantage Plan
If you need to go to an out-of-network doctor regularly and not for a 1-time appointment, then it might be a good idea to consider switching to a Medicare Advantage plan. MA plans generally have a wider coverage network than Medicare and might be in-network with the provider you want to see.
What This Means For You
Medicare covers many doctor’s visits, from physical therapy sessions to annual wellness visits. It typically pays 80% of each visit. That leaves you with 20% coinsurance.
If you go to the doctor often, these costs can add up, so you may want to consider adding Medigap insurance. Another possible option is a Medicare Advantage plan with more comprehensive coverage. Medicare Advantage plans can cover additional visits like massage therapy or dental services.
Whether you’re sticking with Original Medicare or exploring other options, do your research before any doctor visit so you know what to expect regarding cost.