Does Medicare Pay for Doctor Office Visits?
When scheduling an annual exam or a new patient appointment, it's helpful if you know what your Medicare insurance plan pays for.
Whether you have Original Medicare (Parts A and B), a supplemental policy, or Medicare Advantage, we’ll share more information about what your bill may be after a doctor office visit.
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Does Medicare Cover Doctor Office Visits?
As long as your doctor accepts Medicare assignment (most do), Original Medicare covers annual doctor office check-ups in full. However, there are different types of visits – and potential costs – to know about.
Welcome to Medicare Visit
During the first 12 months in which you have Medicare Part B, you get one free "Welcome to Medicare" preventive visit with your doctor.
This visit has absolutely no out-of-pocket cost to you, whether you have a supplemental policy or not. You'll only be responsible for your Part B deductible or coinsurance if your doctor ends up performing any extra tests or services during the visit.
Annual Wellness Exam
Medicare will cover one free wellness exam per year. Again, there's no copays, coinsurance, or deductible required – the visit is genuinely free.
The exam includes a health assessment, a checklist of preventive screenings, and your typical health checks like blood pressure and weight.
If you have any medical concerns or need treatment for an issue or condition while you’re there, it may go outside of the scope of a wellness exam and have a different billing code.
In that case, if you have a Medicare Supplement, you’ll only be responsible for meeting your annual deductible. After that, your supplement will pick up the Medicare Part B 20% coinsurance.
Medicare Advantage plans typically have office visit copays, which vary depending on which specific plan you have.
You can reach out to us and we will help you understand your benefits with your current plan.
Other Doctor Visits
If you need to see your doctor for something other than an annual check-up, you will have costs under Original Medicare Part B. There’s a 20% coinsurance and an annual deductible.
Did you know a Medicare Supplement may pick up the 20% coinsurance? The plans we recommend most, G and N, cover that coinsurance in full. You’re only responsible for the Medicare Part B annual deductible.
For those with a Medicare Advantage plan, your office visit copay will vary depending on which plan you have. If you’re not sure what your copay is, reach out to us and we can help you understand your plan.
Does Medicare Limit Doctor Visits?
Original Medicare does not limit doctor visits. The Medicare program is Fee-for-Service, meaning you are in control of your care plan. If you want to see a doctor, you absolutely can.
Medicare Advantage (MA), on the other hand, is not Fee-for-Service. MA plans are managed care plans, meaning the private insurance company has rules and guidelines in place for what treatments and prescriptions you can have and when.
Some MA plans also require referrals or prior authorizations. Our team of licensed sales agents can help you look at MA plans and find an option that does not come with these hurdles to care, if that’s important to you.
How Much Does Medicare Pay Doctors for Visits?
Medicare has set amounts for what they pay providers for different services. The amount Medicare pays doctors for visits is entirely dependent on the billing code used for your appointment.
If you have a 5-minute interaction, that should be billed differently than an hour-long visit.
In Macon County, IL, Medicare would pay $35.29 for an established patient visit that lasts between 10-19 minutes (as of 2023).
Whether you need an annual exam or a special office visit, Medicare Part B + a supplemental policy will cover almost all of your out-of-pocket costs. Your only responsibility is the Part B annual deductible.
If you have any questions about your costs in Medicare, please don’t hesitate to schedule an appointment with one of our licensed sales agents.
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