Medicare Part B covers doctor visits and outpatient care — but you have to pay a monthly premium, and then Medicare reimburses part of the cost

Medicare Part B reimbursement means Medicare pays its share of what you owe after you see a doctor, get lab work, or receive outpatient treatment. You are not reimbursed money back into your pocket. Instead, Medicare sends payment directly to the provider, and you pay your share — usually a copay or coinsurance — out of pocket at the time of service or on a bill afterward.

To receive Part B reimbursement, you must be enrolled in Medicare Part B. Most people become may be able to access at age 65, but some younger people with disabilities or end-stage renal disease can join earlier. You pay a monthly premium (the amount varies by income), and then Medicare covers roughly 80 percent of approved services after you meet your annual deductible.

The key point: you do not explore for reimbursement on a case-by-case basis. Reimbursement happens automatically when you use a provider who accepts Medicare. If a provider does not accept Medicare, or if you receive a service Medicare does not cover, you will owe the full cost yourself.

Key Takeaways

  • You must be enrolled in Medicare Part B to receive any reimbursement; enrollment usually happens automatically at 65 if you are already receiving Social Security.
  • Medicare Part B covers doctor visits, lab tests, imaging, and outpatient procedures, but not routine dental, vision, or hearing care.
  • You pay a monthly premium for Part B, and then you owe a deductible and coinsurance on each service — Medicare reimburses its portion directly to the provider.
  • Reimbursement only happens when you see a provider who accepts Medicare; using an out-of-network provider or one who does not accept Medicare means you pay the full bill.
  • Your income affects your Part B premium; higher earners pay a surcharge called Income-Related Monthly Adjustment Amount (IRMAA).

Who is automatically enrolled in Medicare Part B

If you are already receiving Social Security benefits when you turn 65, Medicare Part B enrollment happens automatically. You do not have to do anything. Your Part B coverage starts on the first day of the month you turn 65, and your premium is deducted from your Social Security check each month.

If you are not yet receiving Social Security at 65, you must sign up for Part B yourself during your initial enrollment period — the three months before the month you turn 65, the month you turn 65, and the three months after. Missing this window can result in a permanent penalty on your premium, so contact Social Security or Medicare if you are unsure whether you are enrolled.

Some people become may be able to access for Medicare before 65. If you have been receiving Social Security Disability Insurance (SSDI) for 24 months, or if you have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), you can join Medicare regardless of age. Part B enrollment rules are the same: you must sign up during your enrollment period, or you may face a penalty.

What Part B actually covers and what it does not

Medicare Part B covers doctor office visits, including primary care and specialist appointments. It also covers lab tests, X-rays, CT scans, ultrasounds, and other diagnostic imaging when ordered by a doctor. Outpatient surgery, chemotherapy, dialysis, and rehabilitation services (physical therapy, occupational therapy, speech therapy) are covered as long as they are medically necessary and ordered by a physician.

Part B does not cover routine dental work, eyeglasses, hearing aids, or routine vision exams. It does not cover most preventive care screenings — though it does cover certain screenings like mammograms, colonoscopies, and bone density tests at no cost to you. Prescription drugs are covered under Part D, not Part B. Long-term care, custodial care, and most mental health services beyond a limited number of outpatient visits are not covered.

If you receive a service that Part B does not cover, Medicare will not reimburse any part of it, and you will owe the provider the full amount. Before an expensive procedure, ask your doctor whether Medicare covers it, or call Medicare directly at 1-800-MEDICARE to confirm.

How much you pay: premiums, deductibles, and coinsurance

Your monthly Part B premium is set by Medicare and changes each year. For 2024, the standard premium is $164.90 per month, but your actual premium may be higher if your income is above a certain threshold. This surcharge is called Income-Related Monthly Adjustment Amount (IRMAA), and it is based on your tax return from two years prior.

After you pay your premium, you also owe an annual deductible before Medicare starts paying. For 2024, the Part B deductible is $240. Once you meet the deductible, Medicare typically pays 80 percent of the approved amount for most services, and you pay 20 percent coinsurance. Some services, like preventive screenings, have no coinsurance.

If you cannot afford the premium, you may be able to get help through the Medicare Savings Program (MSP), which is run by your state. MSP can pay your Part B premium, deductible, and coinsurance if your income and resources fall below certain limits. Contact your state Medicaid office or call 1-800-MEDICARE to find out whether you may have access to.

When Medicare Part B does not reimburse

Medicare will not reimburse you if you see a provider who does not accept Medicare. Some doctors, especially specialists, do not participate in Medicare. Before your appointment, ask the office whether they accept Medicare. If they do not, you will owe the full bill, and Medicare will not pay anything toward it.

Medicare also will not reimburse if the service is not medically necessary. For example, if your doctor orders an MRI but Medicare's guidelines say an X-ray is sufficient, Medicare may deny the claim. The provider will send you a notice explaining the denial. You can appeal, but you are responsible for the bill unless the appeal succeeds.

If you receive care from a provider who accepts Medicare but bills you more than Medicare's approved amount, that is called balance billing. Providers who accept Medicare are not allowed to balance bill you. If this happens, report it to Medicare at 1-800-MEDICARE or file a complaint with your state's health department.

Income-Related Monthly Adjustment Amount (IRMAA) and how it affects your premium

If your income is above a certain level, you will pay a higher Part B premium. For 2024, if your modified adjusted gross income (MAGI) is above $97,000 as a single filer or $194,000 as a married couple filing jointly, you owe an IRMAA surcharge on top of the standard premium.

The surcharge is tiered: the higher your income, the more you pay. At the highest income level, your Part B premium can be three or four times the standard amount. IRMAA is calculated using your tax return from two years before, so if your income drops significantly, you can request a recalculation by contacting Social Security.

IRMAA also applies to Part D (prescription drug) premiums and Part A (hospital insurance) if you are not yet 65 and receiving SSDI. If you experience a major life event — job loss, divorce, death of a spouse — that significantly reduces your income, you can ask Social Security to recalculate your IRMAA using your current year's income instead of the prior year's.

Medigap and Medicare Advantage: how they change reimbursement

Original Medicare Part B works the way described above: you pay your share, and Medicare reimburses the provider. But you can also choose Medigap (supplemental insurance) or Medicare Advantage (Part C), which change how reimbursement works.

Medigap is private insurance that pays some or all of your coinsurance and deductible. If you have Medigap, you still have Part B, but your Medigap plan covers your 20 percent coinsurance, so you pay little or nothing at the point of service. You pay a separate Medigap premium to the insurance company.

Medicare Advantage is an alternative to Original Medicare. Instead of Part B, you enroll in a private plan (usually an HMO or PPO) that covers hospital, doctor, and prescription drug services. Reimbursement works differently: you may have copays instead of coinsurance, and you must use in-network providers. If you choose Medicare Advantage, you do not have Part B, so the information above does not explore to you.

Frequently Asked Questions

Do I have to pay for Part B if I am still working at 65?

You are not required to enroll in Part B if you or your spouse are still working and covered by an employer health plan. You can delay Part B without penalty as long as you are covered by an active employer plan. When you leave your job, you have eight months to sign up for Part B without penalty. If you miss this window, you will owe a permanent surcharge on your premium.

What happens if I do not pay my Part B premium?

If you do not pay your Part B premium, your coverage will be terminated. You can reinstate it by paying the back premiums, but you may face a gap in coverage. If you cannot afford the premium, contact your state Medicaid office about the Medicare Savings Program, which can pay your premium for you.

Can I get reimbursed for services I paid for before I enrolled in Part B?

No. Medicare only reimburses services you receive after your Part B coverage begins. If you received medical services before you were enrolled, you cannot go back and claim reimbursement. This is another reason to enroll during your initial enrollment period.

Does Medicare Part B cover telehealth visits?

Yes. Medicare Part B covers telehealth visits with doctors who accept Medicare, and reimbursement works the same way as in-person visits. You pay your deductible and coinsurance, and Medicare pays its share. Make sure the provider accepts Medicare before your appointment.

What if my doctor retires or stops accepting Medicare?

You will need to find a new doctor who accepts Medicare. Your current doctor should provide your medical records. You can search for Medicare-accepting providers on Medicare.gov or call 1-800-MEDICARE for a list of doctors in your area.