Medicare covers most doctor visits, but you will pay a share of the cost

Medicare Part B covers visits to your doctor's office, urgent care clinics, and emergency rooms. You do not pay the full bill — Medicare and you split the cost. How much you pay depends on what type of visit it is, whether your doctor accepts Medicare rates, and which part of Medicare you have.

The basic rule: Medicare pays 80 percent of the approved amount for most doctor visits after you meet your yearly deductible. You pay the other 20 percent, plus the deductible itself. If your doctor does not accept Medicare, you may pay more. If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower.

Key Takeaways

  • Medicare Part B covers office visits, urgent care, and emergency room visits after you meet your annual deductible, which is $240 in 2024.
  • You pay 20 percent of the Medicare-approved amount for most doctor visits; Medicare pays 80 percent.
  • Doctors who accept Medicare assignment charge only the approved amount; doctors who do not accept assignment can charge up to 15 percent more.
  • Preventive visits like annual wellness exams and certain screenings are covered at no cost to you if your doctor accepts Medicare rates.
  • Medicare Advantage and Medigap plans change how much you pay out of pocket, so your actual costs depend on which plan you chose.

How the 80/20 split works for routine office visits

When you see your doctor for a regular visit, Medicare approves a certain amount for that service. Let's say the approved amount is $100. You pay $20 (your 20 percent), and Medicare pays $80 (its 80 percent) — but only after you have paid your deductible for the year.

Your deductible is the amount you must pay out of your own pocket before Medicare starts paying its share. For 2024, the Part B deductible is $240. Once you reach $240 in out-of-pocket costs for covered services, Medicare begins paying 80 percent of approved amounts for the rest of the year.

This 80/20 split applies to most doctor visits: office visits for illness or injury, consultations with specialists, and follow-up appointments. It does not explore to preventive care, which has its own rules.

Preventive visits and screenings covered at no cost

Medicare covers certain preventive services at no cost to you — you pay nothing, even before you meet your deductible. These include your annual wellness visit (a check-up focused on prevention), blood pressure checks, diabetes screening, cholesterol screening, and certain cancer screenings like mammograms and colonoscopies.

The catch: your doctor must accept Medicare assignment (meaning they accept the Medicare-approved rate as full payment). If your doctor does not accept assignment, they can charge you for the preventive visit, even though Medicare considers it preventive.

To confirm that a preventive service is covered at no cost, ask your doctor's office before your visit. You can also check Medicare.gov or call Medicare at 1-800-MEDICARE to verify which preventive services are included.

What happens if your doctor does not accept Medicare

Some doctors do not accept Medicare at all. If your doctor is non-participating, they can charge you whatever they want — there is no limit. You will pay the full bill and then submit it to Medicare yourself. Medicare will reimburse you for 80 percent of the approved amount (after your deductible), but you may still owe the difference between what the doctor charged and what Medicare approved.

More common is a doctor who accepts Medicare but does not accept assignment. These doctors can charge up to 15 percent more than the Medicare-approved amount. For example, if Medicare approves $100, they can charge you $115. You pay 20 percent of $115 ($23), and Medicare pays 80 percent of the approved $100 ($80). You cover the extra $15 yourself.

Before scheduling an appointment, ask your doctor's office: "Do you accept Medicare assignment?" If the answer is no, ask what they will charge and whether you can get an estimate in writing.

Emergency room visits and urgent care

Emergency room visits are covered under Part B. You pay 20 percent of the approved amount after your deductible, the same as a regular office visit. If the hospital admits you as an inpatient, Part A (hospital insurance) takes over instead, and your costs change.

Urgent care clinics are also covered at the 80/20 split. However, some urgent care centers are not in-network with Medicare, meaning they do not accept Medicare assignment. Call ahead to confirm the clinic accepts Medicare and what your out-of-pocket cost will be.

If you go to an out-of-network emergency room, Medicare still covers it, but you may pay more. Keep your receipt and any bills — you will need them to file a claim with Medicare.

How Medicare Advantage and Medigap plans change your costs

If you chose a Medicare Advantage plan (Part C) instead of Original Medicare, your doctor visit costs work differently. Most Medicare Advantage plans charge a copay for office visits — typically $10 to $50 per visit — instead of the 20 percent coinsurance. Some plans cover preventive visits with no copay. Your out-of-pocket maximum is capped, so your costs cannot exceed a certain amount per year.

If you have Original Medicare plus a Medigap (supplemental insurance) plan, Medigap covers some or all of your 20 percent coinsurance, depending on which Medigap plan you chose. For example, Medigap Plan G covers your 20 percent coinsurance for doctor visits after you meet your deductible. With Plan G, you would pay only the $240 deductible and then nothing for covered doctor visits for the rest of the year.

Review your plan documents or call your plan's customer service line to understand your specific costs. The amount you pay for a doctor visit depends entirely on which plan you have.

Telehealth and virtual visits

Medicare covers telehealth visits (video or phone calls with your doctor) under the same rules as in-person visits. You pay 20 percent of the approved amount after your deductible. Preventive telehealth visits are also covered at no cost if your doctor accepts Medicare assignment.

Not all doctors offer telehealth, and not all telehealth platforms accept Medicare. Ask your doctor whether they offer video or phone visits and whether Medicare will cover them. If you use a telehealth service directly (not through your doctor), confirm that the provider accepts Medicare before your visit.

Frequently Asked Questions

Do I have to pay my deductible every year?

Yes. The Part B deductible resets on January 1 each year. Once you reach $240 in out-of-pocket costs for covered services in a calendar year, Medicare begins paying 80 percent of approved amounts for the rest of that year. The deductible amount may change each year.

What if I see a doctor who is out of state?

Medicare covers doctor visits anywhere in the United States, including out-of-state visits. The same 80/20 split applies. Confirm that the out-of-state doctor accepts Medicare assignment before your visit to avoid surprise bills.

Are lab tests and X-rays covered the same way as doctor visits?

Lab tests and X-rays ordered by your doctor are covered under Part B, and you pay 20 percent of the approved amount after your deductible. Some preventive lab tests (like cholesterol screening) are covered at no cost. Ask your doctor's office what you will owe before the test.

What if my doctor's bill is higher than what Medicare approved?

If your doctor accepts Medicare assignment, they cannot charge you more than the approved amount. If they do not accept assignment, they can charge up to 15 percent more. You are responsible for the difference. Always ask in advance whether your doctor accepts assignment.

Can I see any doctor I want with Medicare?

Yes, with Original Medicare you can see any doctor who accepts Medicare, anywhere in the country. You do not need a referral. Medicare Advantage plans often require you to use in-network doctors, so check your plan's provider list before scheduling an appointment.