Your doctor helps you stay healthy and manage your chronic health conditions, but how much do those visits cost, how much does Medicare cover and what’s your share of the bill?
The answers to those questions depend on several factors, from the length of the visit, to where you live, to the type of Medicare coverage you have.
Original Medicare vs. Medicare Advantage
Under Original Medicare, Part B covers the cost of a doctor visit, and this coverage isn’t free.
In 2022, Part B has a standard monthly premium of $170.10 and a deductible of $233. After meeting the deductible, you’ll pay 20 percent of the Medicare-approved amount for most doctor services.
However, preventative services, such as an annual wellness visit and vaccinations, won’t cost you anything.
If you have Medicare Advantage (Part C), you’ll likely have some combination of premium, copays, coinsurance and deductible. What you pay out of pocket for a visit will depend on the specifics of your plan.
Does Medicare Part B cover 100 percent of a doctor’s visit?
It depends. You don’t have to pay out of pocket for most preventative services, such as an annual wellness visit with your doctor, some vaccinations and some health screenings.
However, if a doctor performs additional tests or services during the wellness visit that exceed the preventative benefit, you may have to pay.
For visits that aren’t considered preventative services, you’ll pay the Medicare-approved amount until you reach the $233 deductible. After that, you’ll pay 20 percent of the cost.
Remember, for Medicare to pay any cost, the service has to be deemed medically necessary. That means it meets accepted medical standards and is required to diagnose or treat a medical condition. If Medicare doesn’t cover a service, you may be on the hook for the cost.
Also, your doctor has to accept assignment. That means the doctor agrees to be paid a certain amount directly by Medicare and not bill you extra. If your doctor doesn’t accept assignment, you could be stuck paying extra.
What is the Medicare-approved amount for a doctor visit?
This would seem like a simple question, but the answer depends on several factors, including how long the visit takes and the location.
For example, the Medicare-approved amount for an office visit with a new patient in Ohio ranges from $82.98 to $217.28, depending on the complexity of the visit and whether it takes place in a doctor’s office (non-facility) or a hospital (facility).
And if the doctor doesn’t take assignment, the charges are different altogether, and you’ll pay even more.
Another thing to keep in mind is Medicare-approved amounts vary from state to state.
In Los Angeles, California, the Medicare-approved amount for those same office visits ranges from $89.73 to $243.48.
Are there copays with Medicare?
If you have Medicare Part B, you have a $233 deductible, and you typically will pay 20 percent of the Medicare-approved amount for a service after hitting your deductible. That is called coinsurance.
If you have Medicare Advantage (Part C), your plan may have a deductible, coinsurance or a copayment. The latter is a fixed amount, such as $20, for a service.
Each Medicare Advantage plan is different, but all have a yearly limit on what you have to pay out of pocket.
What is Medicare Giveback?
Some Medicare Advantage (Part C) plans cover all or part of your Part B monthly premium. This is sometimes called Medicare Giveback. To get this benefit you need to be enrolled in such a plan.
Where can I find a primary care physician who accepts Medicare patients?
NewPrimaryCare.com can help you find a quality Medicare primary care doctor near you. All of our provider partners practice value-based care, meaning Medicare rewards them for helping patients get healthier, rather than for the number of patients they treat. With a value-based care provider, you can expect quicker appointment scheduling, shorter waits at the doctor’s office and a meaningful connection with your physician.
Use our Find Your Doctor tool to search for and compare value-based care providers near you.