What Medicare Covers for Doctor Visits and What You Pay

Medicare covers most doctor visits, but you 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 pays its portion and you pay yours. The amount you pay depends on whether your doctor accepts Medicare, what type of visit it is, and which part of Medicare you have.

The key difference is this: Medicare Part B pays 80 percent of the approved amount for most doctor visits after you meet your annual deductible. You pay the remaining 20 percent, called coinsurance. If your doctor does not accept Medicare, you may owe significantly more.

Key Takeaways

Medicare Part B covers doctor visits at 80 percent after you pay your annual deductible; you pay the remaining 20 percent coinsurance.
Doctors who accept Medicare charge only the Medicare-approved amount; doctors who do not accept Medicare can charge you more.
Your actual out-of-pocket cost varies by doctor, type of visit, and whether you have supplemental coverage like Medigap or a Medicare Advantage plan.
Preventive visits like annual wellness exams and certain screenings are covered at 100 percent with no coinsurance.
You should ask your doctor's office whether they accept Medicare and what your cost will be before your visit.

How Medicare Part B pays for doctor visits

When you see a doctor who accepts Medicare, here is how the payment works. Medicare sets an approved amount for each type of visit — for example, an office visit for a new patient or a follow-up for a chronic condition. Medicare pays 80 percent of that approved amount. You pay 20 percent, which is your coinsurance.

Before Medicare pays anything, you must first meet your Part B deductible for the year. In 2024, that deductible is $240. Once you have paid $240 out of pocket toward covered services, Medicare begins paying its 80 percent share. Until then, you pay 100 percent of the approved amount.

This means your first few doctor visits of the year may cost you more, because you are still working toward your deductible. After you meet it, your cost per visit drops to 20 percent of the approved amount.

What happens if your doctor does not accept Medicare

Some doctors do not accept Medicare at all. These are called non-participating providers. If you see a non-participating doctor, you may owe much more than 20 percent.

A non-participating doctor can charge up to 15 percent more than Medicare's approved amount. So instead of paying 20 percent coinsurance on the approved amount, you could pay 20 percent coinsurance plus the extra 15 percent markup. You are also responsible for paying the full bill upfront and seeking reimbursement from Medicare yourself.

Before you schedule a visit with any doctor, ask their office: "Do you accept Medicare?" If they say no, ask what they charge and whether they will submit the claim to Medicare for you. Some non-participating doctors will file the claim; others will not.

Preventive visits and screenings covered at no cost

Medicare Part B covers certain preventive services at 100 percent — meaning you pay nothing, even before you meet your deductible. These include your annual wellness visit, cancer screenings, cardiovascular screenings, and diabetes screenings.

The annual wellness visit is a one-time appointment each year where your doctor reviews your health history, takes your vital signs, and discusses preventive care. This visit is free. However, if your doctor finds a problem during that visit and you need additional testing or treatment, those services may not be free and will count toward your deductible.

Other fully covered preventive services include mammograms, colonoscopies, bone density scans, and flu shots. The full list is available on Medicare.gov. If you are unsure whether a specific screening is covered, call your doctor's office or Medicare at 1-800-MEDICARE before your visit.

How Medigap and Medicare Advantage plans change what you pay

If you have a Medigap (supplemental insurance) plan, it covers some or all of your 20 percent coinsurance. Depending on which Medigap plan you have, you may pay nothing out of pocket for doctor visits after you meet your Part B deductible. Medigap does not change what Medicare pays — it only covers your share.

If you have a Medicare Advantage plan instead of Original Medicare, the rules are different. Medicare Advantage plans set their own copays and coinsurance amounts. You might pay a flat copay per visit (for example, $15 or $25) instead of 20 percent coinsurance. Your out-of-pocket costs depend on your specific plan and whether you see an in-network or out-of-network doctor.

Check your plan documents or call your plan's customer service number to find out what you will pay for a doctor visit. The amount varies widely between plans.

Telehealth visits and what Medicare covers

Medicare Part B covers telehealth visits — appointments by video or phone with your doctor — under the same rules as in-person visits. You pay 20 percent coinsurance after your deductible, and preventive telehealth visits are covered at 100 percent.

Not all doctors offer telehealth, and some may charge differently for phone visits than video visits. Ask your doctor's office whether they offer telehealth and what the cost will be. If you use telehealth, make sure you are seeing a Medicare-participating provider, because the same rules about non-participating doctors explore.

What to do before your visit

Call your doctor's office at least a few days before your appointment and ask three things: Does the doctor accept Medicare? What is the visit cost? Will they file the claim to Medicare, or will you need to?

Bring your Medicare card to every visit. If you have a Medigap or Medicare Advantage plan, bring that card too. The doctor's office needs both to process your claim correctly.

If you are seeing a new doctor, ask whether they are accepting new Medicare patients. Some doctors have stopped accepting Medicare or have closed their practices to new Medicare patients, so it is worth confirming before you schedule.

Frequently Asked Questions

Do I have to pay my 20 percent coinsurance upfront, or does Medicare pay first?

It depends on the doctor's office. Most Medicare-participating doctors bill Medicare first, then send you a bill for your 20 percent coinsurance. You pay after Medicare pays. Some offices may ask you to pay upfront and then seek reimbursement from Medicare, but this is less common.

What if I have not met my deductible yet and I see my doctor?

You pay 100 percent of the Medicare-approved amount until you reach your $240 deductible. Once you have paid $240 toward covered services in that calendar year, your coinsurance drops to 20 percent for the rest of the year.

Are urgent care visits covered the same way as regular doctor visits?

Yes, if the urgent care center accepts Medicare. You pay 20 percent coinsurance after your deductible, just as you would at your doctor's office. Call ahead to confirm they accept Medicare and ask about the cost.

What if my doctor charges less than the Medicare-approved amount?

If a Medicare-participating doctor charges less than the approved amount, you pay 20 percent of what they actually charge, not 20 percent of the approved amount. This is rare, but it means your cost is lower.

Can I see a specialist without a referral on Medicare?

Yes. Original Medicare does not require referrals to see specialists. You can call a specialist's office directly and schedule an appointment. If you have a Medicare Advantage plan, check your plan documents — some Medicare Advantage plans do require referrals.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.