Medicare Part B and Part C, also known as Medicare Advantage, cover visits to the doctor.
Medicare is a federally funded insurance plan. There are four parts to Medicare: Part A, Part B, Part C, and Part D. Each part covers different medical expenses.
According to figures from the Kaiser Family Foundation (KFF), Medicare provided healthcare benefits for 53.5 million older adults in 2015. This number jumped to 59.9 million in 2018.
Today, Medicare covers older adults over age 65, younger people with disabilities, and people with end stage kidney disease.
In this article, learn which Medicare plans cover doctor visits, what types of appointments they cover, and how much the plans cost.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Part B is part of Traditional Medicare, which consists of Part A or Part B.
Medicare Part B
Medicare B covers two types of services.
- Medically necessary: These are services the doctor uses to identify a medical condition and provide treatment when someone presents with symptoms.
- Preventive service: This type of care helps prevent illnesses or catch them early. They include screenings and flu shots. Examples of adult preventive screenings include cholesterol checks, Pap smears, and mammograms.
Preventive services may be free when the doctor agrees to accept the assignment. This means that the doctor has a contract to bill Medicare directly.
Part B may also pay for other services, like an ambulance, some prescription drugs, and medical equipment. People can check whether their plan covers the test or service they need at Your Medicare Coverage.
Medicare Part C (Medicare Advantage)
Medicare Part C covers doctor visits a little differently. The program is called Medicare Advantage and is available through private companies.
The Plans are sometimes called “MA plans,” or an all-in-one alternative to Traditional Medicare.
All Medicare Advantage Plans must cover anything covered by Traditional Medicare, including visits to the doctor.
Medicare Advantage Plans do not cover services that are not medically necessary under Traditional Medicare.
Medicare sends payment to the doctor, and the doctor cannot charge the person more than the plan allows.
Individuals may be responsible for coinsurance or a deductible. This is usually 20% of the cost.
The coinsurance is the amount a person owes a doctor or service provider for the doctor’s appointment. Medicare set this rate, and it is often 20% of the bill.
The deductible is the amount of money a person pays out-of-pocket before insurance begins to pay. The deductible in 2020 for the year is $198.00.
The overall costs for Part B depend on a person’s income and when they enrolled. The charges include a premium, coinsurance, deductible, and a possible penalty.
A premium is a price a person pays to keep the policy. The standard premium in 2020 is $144.60 each month.
If a person did not sign up when they were eligible at age 65, there might be a late enrollment penalty. This penalty can increase the premiums by 10%.
An individual’s cost for Medicare Advantage Plans varies, depending on several factors. These can include:
- whether the plan has a premium
- whether the plan pays the Medicare Part B premium
- a yearly deductible, copayment, or coinsurance
- an annual limit on out-of-pocket expenses
- the type of healthcare services a person needs
Medicare Part B does not limit an individual’s visits to the doctor. However, there are limits on the types of services in a year or lifetime.
For instance, a person can have blood tests to screen for heart disease once every 5 years.
Individuals covered by Medicare Part B can have unlimited medically necessary physical therapy every year. Medicare has a list of covered benefits, how often a person can use them, and links to get more information.
Medicare does not typically cover some services and doctor’s appointments, including:
- podiatry, including callous removal, corn removal, or toenail trimming
- optometry, including regular eye health check ups and getting a new prescription
- naturopathic medicine, including acupuncture
- dental services, although Medicare Advantage may cover some dentistry,
- most chiropractic services, unless they are for certain conditions, such as spinal subluxation
Medicare Part B and C (Medicare Advantage) cover visits to the doctor.
Both plans help older adults pay for medically necessary and preventive care. Individuals should enroll close to their 65th birthday to avoid a penalty charge.
Medicare does not limit the number of times a person can see their doctor, but it may limit the number of times a person can have a particular test and access other services.
It is best to contact Medicare directly on 1-800-MEDICARE to discuss physician coverage in further detail.