Medicare Part B is the part of original Medicare that covers the costs of doctor visits. Part C, or Medicare Advantage, also provides this coverage.
Medicare is a federally funded insurance plan consisting of four parts: Part A, Part B, Part C, and Part D. Each part covers different medical expenses.
In 2020, Medicare provided healthcare benefits for more than 61 million older adults and other qualifying individuals.
Today, it primarily covers people who are over the age of 65 years, but younger people with end stage kidney disease and those with certain disabilities are also eligible.
This article explains which parts of Medicare 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
Medicare Part B covers two types of services: medically necessary and preventive.
Medically necessary services are those that the doctor uses to identify a medical condition when someone presents with symptoms and to provide them with treatment.
Preventive care helps prevent illnesses or stop early stage conditions from progressing. This type of care includes flu shots and screenings, such as cholesterol checks, Pap smears, and mammograms.
Some preventive services have no associated costs when a doctor agrees to accept assignment. This means that the doctor has a contract to bill Medicare directly.
Part B may also pay for other services, such as an ambulance, certain prescription drugs, and durable medical equipment. People can check whether their plan covers the test or service they need using Medicare’s online tool.
Medicare Part C (Medicare Advantage plans)
Medicare Part C plans, also known as Medicare Advantage plans, are an all-in-one alternative to original Medicare that private insurance companies administer. These plans must provide the same coverage level as original Medicare, including coverage for visits to the doctor.
Medicare sends payment directly to the doctor, although individuals may need to pay a coinsurance and meet a deductible. These costs vary by plan.
Medicare typically does not cover certain services and doctor’s appointments, including:
- podiatry, which can involve callous removal, corn removal, or toenail trimming
- optometry, including regular eye health checkups and getting a new prescription
- naturopathic medicine, including acupuncture — unless it is to treat lower back pain
- dental services, although Medicare Advantage may cover some dentistry
- most chiropractic services, unless they are for spinal subluxation
Part B may limit coverage to a set number of services in a year or lifetime. For example, a person can have blood tests to screen for heart disease once every 5 years.
Everyone with Medicare is entitled to a yearly wellness visit that has no charge and is not subject to a deductible.
Beyond that, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. The individual must pay 20% to the doctor or service provider as coinsurance.
The Part B deductible also applies, which is $203 in 2021. The deductible is the amount of money that a person pays out of pocket before the insurance begins to cover the costs.
A person will also need to pay a premium to keep the policy. The standard monthly premium in 2021 is $148.50.
If a person did not sign up when they were eligible at the age of 65 years, they might also need to pay a late enrollment penalty. This penalty can increase the premiums by 10% for each year that someone qualified for Medicare but did not enroll.
The costs associated with Medicare Advantage Plans vary depending on several factors, including:
- whether the plan has a premium
- whether the plan pays the Medicare Part B premium
- the yearly deductible, copayment, or coinsurance
- the annual limit on out-of-pocket expenses
- the type of healthcare services a person needs
Medicare Part B and Medicare Advantage plans cover visits to the doctor. These plans help people with health insurance plans pay for medically necessary and some preventive care.
Medicare does not limit the number of times a person can see their doctor, but it may limit how often they can have a particular test and access other services.
People can contact Medicare directly on 800-MEDICARE (800-633-4227) to discuss physician coverage in further detail.