Yes, Medicare has copays for doctor visits, but the amount depends on which part of Medicare you have and whether your doctor is in-network

If you have Original Medicare (Part A and Part B), you pay 20% of the cost of a doctor visit after you meet your annual deductible. The deductible amount changes each year. Once you hit that deductible, Medicare pays 80% and you pay the remaining 20% for most outpatient services.

If you have a Medicare Advantage plan (Part C), your copay is set by your specific plan and is usually a flat amount — often $10 to $50 per visit — rather than a percentage. The exact copay varies widely between plans and between in-network and out-of-network doctors.

The key difference is predictability: with Original Medicare you pay a percentage that depends on what the doctor charges, while with Medicare Advantage you typically know the exact dollar amount before you go.

Key Takeaways

  • Original Medicare charges 20% of the approved amount after you meet your annual Part B deductible, which is $240 in 2024 but changes yearly.
  • Medicare Advantage plans set their own copays, usually a flat fee per visit that ranges from $10 to $50 depending on the plan and whether the doctor is in-network.
  • Your copay may be different for a specialist visit than for a primary care visit, even within the same plan.
  • If your doctor does not accept Medicare assignment under Original Medicare, you may pay more than the standard copay.

How Original Medicare copays work

Under Original Medicare Part B, you do not pay a copay in the traditional sense. Instead, you pay a deductible first, then a coinsurance amount. The deductible is the amount you must pay out of your own pocket before Medicare starts to pay anything. For 2024, the Part B deductible is $240, but this amount increases most years.

Once you have paid the deductible, Medicare covers 80% of the approved amount for most doctor visits and outpatient services. You pay the remaining 20%. This 20% is your coinsurance. The amount you actually pay depends on what the doctor's approved charge is, not a fixed dollar amount.

For example, if your doctor's approved charge is $100 and you have already met your deductible, you pay $20 and Medicare pays $80. If the approved charge is $200, you pay $40. The percentage stays the same, but your out-of-pocket cost changes based on the service.

How Medicare Advantage copays work

Medicare Advantage plans operate differently. Each plan sets its own copay amounts, which are usually fixed dollar figures rather than percentages. A typical copay for a primary care doctor visit might be $15 to $25, while a specialist visit might be $30 to $50. Some plans have no copay for preventive services like annual wellness visits or certain screenings.

The copay you pay depends on whether you see an in-network doctor or an out-of-network doctor. In-network copays are lower and more predictable. Out-of-network copays are higher, and some plans may not cover out-of-network visits at all except in emergencies. You should check your plan's provider directory before scheduling a visit to know what you will pay.

Medicare Advantage plans also have an annual out-of-pocket maximum, which is a cap on how much you will pay in copays, coinsurance, and deductibles in a given year. Once you reach that limit, the plan pays 100% of covered services for the rest of the year. Original Medicare does not have an out-of-pocket maximum.

Differences between primary care and specialist copays

Most Medicare Advantage plans charge a lower copay for visits to your primary care doctor than for visits to a specialist. A primary care visit might cost $15, while seeing a cardiologist or dermatologist might cost $40 or more. This structure encourages you to see your primary care doctor first and get a referral before seeing a specialist.

Under Original Medicare, there is no difference in the coinsurance percentage between primary care and specialists — you pay 20% either way after meeting your deductible. However, specialists may charge higher approved amounts, so your actual out-of-pocket cost will likely be higher for a specialist visit straightforward because the service costs more.

What happens if your doctor does not accept Medicare assignment

Under Original Medicare, some doctors are "participating providers," meaning they accept Medicare's approved amount as full payment. Other doctors are "non-participating providers," meaning they do not accept the approved amount and may charge you more.

If a non-participating doctor does not accept assignment, you may have to pay the full charge upfront and then seek reimbursement from Medicare yourself. Some non-participating doctors can charge up to 15% more than Medicare's approved amount, though they must tell you this in writing before the visit.

With Medicare Advantage, you are generally required to use in-network doctors, and they must accept the plan's payment. Out-of-network doctors are not bound by the same rules, which is why out-of-network costs are higher or sometimes not covered at all.

Preventive services with no copay

Both Original Medicare and Medicare Advantage cover certain preventive services with no copay or coinsurance. These include annual wellness visits, cancer screenings, cardiovascular screenings, and vaccinations like the flu shot and pneumonia vaccine.

Under Original Medicare, you pay nothing for these preventive services even if you have not met your deductible. Under Medicare Advantage, your plan must cover these services with no copay as well, though the specific services covered may vary slightly by plan.

It is worth asking your doctor which services are considered preventive, because some services that feel preventive — like a visit to address a chronic condition — may not be classified that way and could result in a copay.

Supplemental insurance and copay coverage

Some people with Original Medicare purchase a Medigap policy, which is supplemental insurance that helps pay the copays and coinsurance that Original Medicare does not cover. Depending on which Medigap plan you choose, it may pay part or all of your 20% coinsurance, your deductible, or both.

Medigap policies have their own monthly premiums, so you pay a premium to the insurance company in addition to your Medicare Part B premium. The trade-off is that you know your out-of-pocket costs more clearly, similar to how Medicare Advantage works.

People with Medicare Advantage do not typically buy Medigap, because Medigap is designed to supplement Original Medicare, not Medicare Advantage. Instead, some people with Medicare Advantage buy a separate policy called a Medicare Advantage supplemental plan, though these are less common.

Frequently Asked Questions

Do I pay a copay for telehealth visits with Medicare?

Yes. Original Medicare covers telehealth visits and charges the same 20% coinsurance as in-person visits after you meet your deductible. Medicare Advantage plans cover telehealth and charge the same copay as an in-person visit, though some plans may offer lower copays for telehealth to encourage its use.

What if I see a doctor before I meet my deductible?

Under Original Medicare, you pay the full approved amount until you reach your deductible. Once you hit the deductible, you then pay 20% coinsurance. Medicare Advantage plans typically have a separate deductible for doctor visits, and you pay the full copay or coinsurance until that deductible is met.

Can my copay change during the year?

Your Medicare Advantage copay amounts are set when you enroll and do not change mid-year. However, if you switch plans during the annual enrollment period, your new plan's copays take effect January 1. Original Medicare copays (the 20% coinsurance) do not change during the year, but the deductible amount changes each January.

Do I pay a copay for emergency room visits?

Yes, but the copay is usually higher than a regular doctor visit. Under Original Medicare, you pay 20% coinsurance after your deductible. Medicare Advantage plans typically charge $100 to $300 for an emergency room visit, though this copay is often waived if you are admitted to the hospital.

What if I go to an out-of-network doctor with Original Medicare?

Original Medicare is accepted nationwide, so there is no "out-of-network" concept the way there is with Medicare Advantage. However, if your doctor does not accept Medicare assignment, you may pay more than the standard 20% coinsurance. Always verify that your doctor accepts Medicare before scheduling a visit.