When Does Medicare Cover Doctors Visits?
- When does Medicare cover doctors visits? Learn which medical visits are covered and which aren't and be prepared for the required deductibles and copayments.
Regular doctor visits are an important part of any healthy lifestyle, which is why there are many occasions when Medicare covers doctors visits.
Most doctors recommend an annual visit to discuss health risks, record vital signs such as weight and blood pressure and develop plans to improve health. Regular visits can also help doctors detect certain conditions in the early stages, improving your chances of successful treatment.
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When Does Medicare Pay for Doctors Visits?
In Original Medicare, certain doctor's office visits are covered by Part B, which is your Original Medicare outpatient coverage.
Doctor visits are also covered for people on a Medicare Advantage (Medicare Part C) Plan. Medicare covers 80% of the costs doctors visits for medically necessary treatment after you met your Part B deductible. Some preventive services, such as annual wellness visits, may be covered fully by Part B.
For both Original Medicare and Medicare Advantage beneficiaries, doctor choice can be limited.
People in Original Medicare must visit a health care provider that’s Medicare-approved and who accepts assignment, which means they’re willing to take the Medicare payment.
Medicare Advantage plans can limit payment to healthcare providers who are in network.
How Much Do I Pay?
Although doctors visits are covered by Medicare, there are still costs for beneficiaries.
First, program enrollees must meet the annual deductible before Medicare makes any payment for medically necessary services. This means that you must pay a certain amount on medical bills each year before coverage begins. In 2024, the annual deductible was $240.
Once you’ve met the deductible, Medicare covers 80% of the Medicare-approved costs of the visit. Beneficiaries are responsible for the other 20%. Medicare also covers 80% of the Medicare-approved cost for preventive doctor visits. This is paid, even if the annual deductible hasn’t been met.
Medicare Supplement Insurance, also known as Medigap, can help pay for deductibles, copays and coinsurance.
Which Medical Visits Are Covered?
Medicare covers most visits to medical doctors (MDs) and doctors of osteopathic medicine (DOs). It can also cover visits to a range of other health practitioners, including:
- Clinical psychologists
- Clinical social workers
- Nurse practitioners
- Occupational therapists
- Physical therapists
Which Medical Visits Are Not Covered?
There are instances when Medicare doesn’t cover doctors visits. This includes dentist visits, naturopathic medicine and most optometrist and chiropractic services. However, some services that aren’t covered by Original Medicare may be covered under the additional benefits in a Medicare Advantage Plan.
It’s always best to check with Medicare or your Medicare Advantage provider before you make an appointment to ensure that you won’t be liable for the cost.
How Often Does Medicare Pay for Annual Wellness Visits?
During your first year of enrollment in Medicare Part B or Medicare Advantage, you’re entitled to a “Welcome to Medicare” visit. Your doctor will take vital information, such as height, weight and blood pressure. During the visit, your doctor also checks risk factors for medical conditions, reviews your medical history and may recommend tests and screening for different conditions.
After the first 12 months enrolled in Medicare, you’re entitled to annual wellness checks. During these visits, your doctor performs a health risk assessment, takes your vitals and works with you to develop a preventative plan to maintain or improve your health.
Annual wellness visits are different from annual physicals as there is no physical exam, and blood work and lab tests aren’t part of the visit.
Medicare pays 100% of the fee for an annual wellness visit and the deductible doesn’t apply. However, if your doctor performs additional tests during the visit that aren’t covered under preventive visits, you may need to pay coinsurance.
Annual physicals aren’t covered by Medicare, so be sure to ask for an annual wellness visit when booking your appointment.
