Does Medicare Cover Doctor’s Visits?

Medicare is a federal health insurance program primarily for individuals aged 65 or older, though it also extends to younger people with certain disabilities or specific medical conditions. The extent of coverage for doctor visits depends on the specific parts of Medicare an individual enrolls in, as the program is structured into several distinct components.

Medicare Parts and Doctor Visit Coverage

Medicare’s various parts determine how doctor visits are covered. Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Private companies offer Medicare Advantage Plans (Part C) as an alternative way to receive Medicare benefits.

Medicare Part A primarily covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Part A does not cover outpatient doctor visits.

Medicare Part B is the primary component that covers doctor visits. This part helps pay for medically necessary services and various preventive services. These include visits to primary care providers and specialists, outpatient care, durable medical equipment, and certain laboratory tests.

Medicare Part C, or Medicare Advantage, plans are offered by private insurance companies approved by Medicare. These plans must provide at least the same level of coverage as Original Medicare (Parts A and B), including doctor visits. Medicare Advantage plans often have their own rules, costs, and provider networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Many Part C plans also include additional benefits not covered by Original Medicare, such as prescription drug coverage or routine dental, vision, and hearing care.

Covered Doctor Visit Services

Medicare Part B covers a range of doctor visit services, broadly categorized into medically necessary care and preventive services. Medically necessary services are those needed to diagnose or treat an illness, injury, condition, or its symptoms, meeting accepted medical standards. Examples include visits for an illness or injury.

Preventive services aim to prevent illness or detect health conditions early. Medicare covers a one-time “Welcome to Medicare” preventive visit within the first 12 months of Part B enrollment. Beneficiaries also receive a yearly Annual Wellness Visit, which focuses on developing or updating a personalized prevention plan.

The Annual Wellness Visit is not a traditional physical exam. It includes routine measurements, a review of medical and family history, and a screening schedule, but generally does not involve a physical examination or lab tests. Routine annual physical exams are typically not covered by Original Medicare.

Medicare also covers visits to specialists, such as cardiologists or dermatologists, when medically necessary. Diagnostic services, including tests like X-rays, laboratory tests, and MRIs, are covered under Part B when ordered by a doctor. Various screenings for conditions like cancer, diabetes, and cardiovascular disease are also covered, along with vaccinations for influenza, pneumonia, and Hepatitis B.

Your Financial Responsibility for Doctor Visits

Under Original Medicare Part B, beneficiaries have specific financial responsibilities. An annual deductible must be met before Medicare pays its share. For 2025, the Part B annual deductible is $257.

After the deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services, known as coinsurance. Medicare pays the remaining 80%. This cost-sharing applies to medically necessary services and some preventive services.

When a doctor or provider “accepts assignment,” they agree to accept the Medicare-approved amount as full payment. They cannot charge more than the Medicare deductible and coinsurance. If a provider does not accept assignment, they can charge up to 15% more than the Medicare-approved amount, known as an “excess charge,” which you pay in addition to the coinsurance.

Medicare Advantage (Part C) plans have different cost-sharing structures. These plans may include copayments, deductibles, and coinsurance. Costs vary significantly between plans, but Medicare Advantage plans must have an annual out-of-pocket maximum.

Choosing Providers and Understanding Billing

For those with Original Medicare, most doctors and hospitals accept Medicare. The official Medicare website offers a “Physician Compare” tool to locate providers who accept Medicare and agree to “accept assignment.”

If you are enrolled in a Medicare Advantage (Part C) plan, you typically need to use doctors and providers within the plan’s specific network. These plans often operate with provider networks (HMOs or PPOs), and going outside the network can result in higher costs or no coverage for non-emergency care. Check the plan’s provider directory to ensure your preferred doctors are in-network. Some HMO plans may require referrals to see specialists.

After a doctor’s visit, the provider’s office submits a claim to Medicare or your Medicare Advantage plan. Once processed, you receive an “Explanation of Benefits” (EOB) from Medicare or a similar statement from your Medicare Advantage plan. This document details services, approved amounts, and what Medicare or your plan paid. Your doctor’s office will then bill you for your remaining share, including any applicable deductible, coinsurance, or copayment.