How Many Doctor Visits Does Medicare Cover?

Medicare is a federal health insurance program for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. This article clarifies Medicare’s coverage for doctor visits, helping beneficiaries understand their benefits and financial responsibilities.

Understanding Original Medicare Coverage for Doctor Visits

Original Medicare is composed of Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Part B primarily covers outpatient doctor visits, including those to primary care physicians and specialists. There is no fixed limit on the number of medically necessary doctor visits covered by Part B. Medically necessary services are those appropriate and needed for diagnosis or treatment, meeting accepted medical standards.

Part B also covers various preventive services. An important preventive benefit is the Annual Wellness Visit, available to beneficiaries who have had Medicare Part B for at least 12 months. This visit focuses on creating or updating a personalized prevention plan based on an individual’s health risks and current health status. It is distinct from a comprehensive physical exam.

Part B also covers diagnostic tests and durable medical equipment when ordered by a doctor, including X-rays, lab tests, and certain medical supplies. Services from various healthcare professionals are covered, including medical doctors, doctors of osteopathic medicine, nurse practitioners, physician assistants, and clinical psychologists.

While Part B handles outpatient doctor services, Medicare Part A covers doctor services received during an inpatient hospital stay. If a patient is formally admitted to a hospital, the services provided by doctors as part of that inpatient care fall under Part A. Doctor visits in an outpatient setting, even within a hospital, are typically covered by Part B.

Medicare Advantage Plans and Doctor Visits

Medicare Advantage plans, also known as Medicare Part C, offer an alternative way to receive Medicare benefits through private companies approved by Medicare. These plans must cover at least all the same services as Original Medicare Part A and Part B. Doctor visits are covered, but access and costs can differ.

Many Medicare Advantage plans have network restrictions. Health Maintenance Organizations (HMOs) generally require beneficiaries to use doctors and hospitals within the plan’s network, often necessitating referrals to specialists. Preferred Provider Organizations (PPOs) offer more flexibility, allowing beneficiaries to see out-of-network providers, though typically at a higher cost.

Cost-sharing structures vary. Instead of Original Medicare’s coinsurance, these plans often use fixed copayments for doctor visits. This often means a set dollar amount for primary care and a different amount for specialist visits. The number of medically necessary visits remains generally unlimited, but the process and out-of-pocket expenses are determined by the specific plan.

Some Medicare Advantage plans offer additional benefits not covered by Original Medicare. These can include routine vision, dental, and hearing care. Such coverage is specific to the individual plan.

Costs Associated with Medicare Doctor Visits

With Original Medicare Part B, beneficiaries typically pay an annual deductible before Medicare begins to cover costs. In 2025, this Part B deductible is $257. After meeting this deductible, Medicare generally pays 80% of the Medicare-approved amount for most covered doctor services, leaving the beneficiary responsible for the remaining 20% coinsurance.

This 20% coinsurance applies to most outpatient doctor visits, therapies, and durable medical equipment. Individuals may also face balance billing if they see a non-participating provider. Medicare Supplement (Medigap) policies can help cover these out-of-pocket costs, including the Part B coinsurance.

Medicare Advantage plans structure costs differently. These plans commonly feature copayments for doctor visits, which are fixed dollar amounts paid at the time of service. The copayment amount for a primary care visit might differ from that for a specialist visit. Many Medicare Advantage plans also have their own deductibles, often for specific services or prescription drugs.

Medicare Advantage plans have an annual out-of-pocket maximum. This limit represents the most a beneficiary will pay for covered Part A and Part B services in a year before the plan pays 100%. In 2025, the maximum out-of-pocket limit for in-network services is $9,350, though individual plans can set lower limits. Original Medicare does not have an out-of-pocket maximum, meaning the 20% coinsurance could continue indefinitely without supplemental coverage.

Specialty Services and Doctor Visits

Mental health services are covered under Medicare Part B, including visits to psychiatrists, psychologists, clinical social workers, and other licensed mental health professionals. Covered services include individual and group psychotherapy, psychiatric evaluations, and medication management. Beneficiaries also receive one annual depression screening at no cost if provided by a primary care doctor.

Telehealth services, using audio and video technology, are covered by Medicare. This allows beneficiaries to receive care remotely for a range of services, including routine office visits, psychotherapy, and consultations. While coverage flexibilities expanded during the pandemic, some rules regarding location of service may change after September 30, 2025, though mental health and substance use disorder services will largely retain home-based coverage. Costs for telehealth visits are generally the same as for in-person visits, with the Part B deductible and 20% coinsurance.

Medicare covers doctor visits in emergency rooms or urgent care centers. If a beneficiary is treated and released from an emergency room without formal hospital admission, these services are covered under Medicare Part B. If the emergency visit leads to an inpatient hospital admission, the doctor’s services during the inpatient stay are covered under Part A.

Home health doctor visits are covered under certain circumstances as part of a home health care plan. For these services to be covered, a doctor must certify that the beneficiary needs part-time or intermittent skilled services and is considered homebound. This includes visits by a doctor or other healthcare provider to oversee skilled nursing, physical therapy, occupational therapy, or speech-language pathology services provided in the home by a Medicare-certified home health agency.