Medicare covers most doctor visits, but what you pay depends on which part of Medicare you have and what type of doctor you see

If you have Original Medicare (Part A and Part B), Medicare pays 80 percent of the cost of a visit to a doctor who accepts Medicare. You pay the remaining 20 percent, plus any yearly deductible you have not yet met. If you have a Medicare Advantage plan (Part C), your coverage works differently — you typically pay a copay (a fixed amount like $20 or $30) per visit instead of a percentage, but you must see doctors in your plan's network.

The key thing to know is that Medicare only pays for visits to doctors who are enrolled in Medicare. If your doctor does not accept Medicare, you will pay the full bill yourself, even if you have Medicare coverage. Before you schedule an appointment, ask the doctor's office whether they accept Medicare and at what rate.

Key Takeaways

  • With Original Medicare, you pay 20 percent of the doctor visit cost after you meet your yearly Part B deductible, and Medicare pays 80 percent.
  • With a Medicare Advantage plan, you usually pay a fixed copay per visit (the amount varies by plan) and must use doctors in your plan's network.
  • Your doctor must be enrolled in Medicare for Medicare to pay anything — if they are not, you pay the full cost out of pocket.
  • Telehealth visits (video or phone calls with your doctor) are covered the same way as in-person visits under both Original Medicare and Medicare Advantage.

How Original Medicare Part B Covers Doctor Visits

Original Medicare Part B covers visits to your primary care doctor, specialists, and other doctors who treat you in an office, clinic, or hospital outpatient setting. After you pay your yearly Part B deductible (which changes each year), Medicare pays 80 percent of what it considers the "approved amount" for the visit. You pay the remaining 20 percent.

The approved amount is not always what the doctor charges. Medicare sets a fee schedule for each type of visit and location. If your doctor charges more than the approved amount, you may owe the difference — unless your doctor has agreed not to charge above Medicare's approved amount. Doctors who agree to this are called "Medicare participating providers." Ask your doctor's office if they are a participating provider before your visit.

Your Part B deductible applies once per year. Once you have paid it, you only owe the 20 percent coinsurance for the rest of that calendar year. If you see multiple doctors in January, you might meet your deductible with the first visit and pay only 20 percent for the others.

Medicare Advantage Plans and Doctor Visit Costs

If you have a Medicare Advantage plan, the plan itself decides what you pay for a doctor visit. Most plans charge a copay — usually between $15 and $50 per visit, depending on whether you see your primary care doctor or a specialist. Some plans charge coinsurance (a percentage) instead of a copay. Your plan documents will tell you exactly what you owe.

Medicare Advantage plans require you to use doctors and hospitals in their network. If you see a doctor outside the network, you typically pay much more or the plan does not cover the visit at all. Before you schedule an appointment with a new doctor, call your plan to confirm the doctor is in network. Many plans have online directories where you can search for doctors by location and specialty.

Some Medicare Advantage plans cover telehealth visits at a lower copay than in-person visits, or with no copay at all. Ask your plan whether telehealth is an option for your type of visit.

What Happens if Your Doctor Does Not Accept Medicare

If your doctor is not enrolled in Medicare, Medicare will not pay for your visit, even if you have Medicare coverage. You will owe the full amount the doctor charges. This is true for both Original Medicare and Medicare Advantage plans.

Some doctors choose not to enroll in Medicare because of the paperwork or the fees Medicare sets. Others may be new to an area and still in the enrollment process. Before you switch doctors or schedule a first appointment, ask the office staff: "Does this doctor accept Medicare?" If the answer is no, ask whether the doctor will submit a claim to Medicare anyway (some will, even if not enrolled) or whether you will pay out of pocket.

Telehealth Visits and Medicare Coverage

Medicare covers telehealth visits — appointments by video or phone — the same way it covers in-person visits. With Original Medicare, you pay 20 percent coinsurance after your deductible. With Medicare Advantage, you pay your plan's copay or coinsurance.

Telehealth visits must be with a doctor who accepts Medicare, just like in-person visits. During the COVID-19 pandemic, Medicare expanded telehealth coverage, and those changes have largely stayed in place. However, some types of visits (such as certain mental health services) may have different rules. If you are unsure whether a telehealth visit is covered, call your doctor's office or your Medicare plan before the appointment.

Specialist Visits and Referrals

With Original Medicare, you do not need a referral to see a specialist. You can call a specialist's office directly and schedule an appointment. Medicare will cover the visit if the specialist accepts Medicare. You will still pay 20 percent coinsurance after your deductible, just as you would for a primary care visit.

With Medicare Advantage, the rules depend on your plan. Some plans require a referral from your primary care doctor before you see a specialist. Others let you see a specialist without a referral but charge a higher copay. Check your plan documents or call your plan to find out what your plan requires.

When Medicare Does Not Cover a Doctor Visit

Medicare does not cover visits for certain services, even if you see a doctor who accepts Medicare. These include routine eye exams (covered by Medicare Part B only if you have diabetes), routine dental care, routine foot care (unless you have diabetes), and hearing exams. If your visit is for one of these services, ask your doctor's office whether the visit will be covered before you go.

Medicare also does not cover visits that are not medically necessary. For example, if you want a doctor to write a letter for a job or school but you do not have a medical reason for the visit, Medicare will not pay. The doctor's office may ask you to pay out of pocket for this type of visit.

Frequently Asked Questions

Do I need to pay anything if I have Original Medicare and my doctor accepts Medicare?

Yes. You pay 20 percent of the approved amount after you meet your yearly Part B deductible. If your doctor charges more than Medicare's approved amount and is not a participating provider, you may owe the difference as well. Call your doctor's office to ask what you will owe before your visit.

What is the difference between a copay and coinsurance?

A copay is a fixed amount you pay per visit — for example, $25. Coinsurance is a percentage of the cost — for example, 20 percent. Original Medicare uses coinsurance. Medicare Advantage plans may use either copays or coinsurance, depending on the plan.

Can I see any doctor I want with Medicare Advantage?

No. You must use doctors in your plan's network. If you see a doctor outside the network, you typically pay the full cost. Some plans cover out-of-network emergency care, but routine visits are usually not covered. Check your plan's directory before scheduling an appointment.

Does Medicare cover virtual visits with my doctor?

Yes. Telehealth visits are covered the same way as in-person visits. With Original Medicare, you pay 20 percent coinsurance. With Medicare Advantage, you pay your plan's copay. The doctor must accept Medicare for the visit to be covered.

What should I do if my doctor does not accept Medicare?

You have two choices: find a different doctor who accepts Medicare, or pay the full cost of the visit out of pocket. You can search for Medicare-accepting doctors on Medicare.gov or call your local senior center for a referral. Some doctors who do not enroll in Medicare will still submit a claim on your behalf — ask the office before your visit.