Key Takeaways

• Medicare does cover doctor visits, but what’s included depends on the part of Medicare you’re enrolled in and whether your doctor accepts Medicare assignment.

• Understanding coinsurance, deductibles, and the types of services covered helps avoid unexpected bills and confusion when accessing care.

How Medicare Handles Doctor Coverage

You might assume that having Medicare means all doctor visits are automatically covered—but that’s not entirely true. In 2025, Medicare remains split into different parts, and each part handles coverage differently. Knowing how each part works helps you better prepare for doctor appointments, costs, and follow-up services.

Understanding Medicare Part B and Doctor Services

For most people, doctor coverage falls under Medicare Part B. This part of Medicare handles what’s called “medically necessary services,” which include:

• Office visits

• Outpatient procedures

• Diagnostic tests (like blood work or X-rays)

• Preventive services (such as screenings and vaccines)

Medicare Part B typically pays 80% of the Medicare-approved amount for these services after you meet your annual deductible. In 2025, that deductible is $257.

What Does It Mean When a Doctor Accepts Assignment?

If a doctor accepts Medicare assignment, it means they agree to the payment terms Medicare sets. These doctors won’t charge you more than the 20% coinsurance once your deductible is met.

If your doctor does not accept assignment, they can legally charge up to 15% more than the Medicare-approved amount, which is known as the “limiting charge.”

Part A and In-Hospital Doctors

Medicare Part A covers your hospital stay—but it also affects how Medicare pays the doctors who see you while you’re admitted. If a doctor treats you during a hospital stay, their services fall under Part B, not Part A. That can be surprising if you assumed everything during a hospital stay is bundled together.

Hospitalists and specialists often bill separately. This means you may see a separate Part B charge from the physician on top of the hospital stay billed under Part A.

Preventive vs. Diagnostic Services

There’s a significant difference in how Medicare handles preventive and diagnostic care, even if they involve similar procedures.

• Preventive services are generally covered in full by Medicare. This includes services like an annual wellness visit, certain cancer screenings, and flu shots.

• Diagnostic services (like follow-up tests after an abnormal screening) are subject to your deductible and coinsurance.

This distinction is important when scheduling services. What starts as a preventive screening could become diagnostic, triggering out-of-pocket costs.

Specialists and Referrals

Unlike some private insurance plans, Medicare doesn’t require a referral to see a specialist. However, your provider network and billing practices still matter.

You can go directly to a specialist as long as they accept Medicare. Just remember:

• The 20% coinsurance applies after the deductible.

• Some specialists might not accept assignment.

• Additional tests or treatments may involve separate billing.

Telehealth in 2025

Telehealth has become a more permanent part of Medicare. In 2025, many telehealth services are still covered, especially for rural beneficiaries or those with limited mobility. Medicare pays for:

• Virtual office visits with primary care providers

• Mental health counseling sessions

• Remote evaluations and monitoring for chronic conditions

If the telehealth service meets Medicare’s criteria and the provider accepts Medicare, you’re generally responsible for the same cost-sharing as in-person visits.

What About Medicare Advantage?

If you’re enrolled in a Medicare Advantage plan (also known as Part C), doctor coverage may be handled differently.

While Advantage plans are required to offer the same core benefits as Original Medicare, they often operate within network-based systems. This means:

• You may need to stay in-network for your doctor visits to be covered.

• You might pay different copays instead of coinsurance.

• Prior authorization could be required for specialist visits.

Since plan details vary, it’s important to review your plan’s summary of benefits each year to understand how your doctor coverage works.

The Role of Medigap in Doctor Coverage

If you have a Medigap plan (Medicare Supplement Insurance), it can help cover the 20% coinsurance that Original Medicare leaves behind.

In 2025, Medigap remains available to help with out-of-pocket costs, but the specific coverage depends on which plan letter you have. For example, some plans pay:

• The full 20% coinsurance for Part B services

• Excess charges from non-participating providers

• Deductibles for Part A and/or Part B (depending on eligibility)

Keep in mind, Medigap only works with Original Medicare—not Medicare Advantage plans.

Out-of-Pocket Costs for Doctor Visits in 2025

Here’s what you can expect to pay when visiting a doctor under Original Medicare in 2025:

• Annual Part B deductible: $257

• Coinsurance: 20% of the Medicare-approved amount after meeting your deductible

• Excess charges: Up to 15% more if your doctor doesn’t accept assignment

• Preventive services: Generally covered in full

If you’re enrolled in a Medigap plan, many of these costs may be partially or fully covered depending on your plan.

Coordinating Medicare with Employer Coverage

If you’re still working past age 65 and have employer coverage, Medicare’s role in covering your doctor visits will depend on how that coverage interacts with Medicare.

• If your employer has 20 or more employees, your employer insurance typically pays first.

• If your employer has fewer than 20 employees, Medicare generally becomes the primary payer.

This coordination affects whether your doctor visit is billed to Medicare, your group plan, or both.

What to Watch for When Choosing a Doctor

To make the most of your Medicare coverage, it’s important to ask the right questions before making an appointment:

• Does the doctor accept Medicare assignment?

• Will there be separate charges for tests or services?

• Does the doctor’s office participate in electronic Medicare billing?

Asking these in advance can prevent surprise bills and ensure you stay within your coverage limits.

When to Appeal a Medicare Doctor Bill

If you believe Medicare should have paid for a service that was denied, you have the right to appeal.

In 2025, the appeals process follows the same general steps:

• Review your Medicare Summary Notice (MSN)

• Submit a written appeal within 120 days

• Include supporting medical documentation

It can take several weeks to receive a decision, but appealing can lead to a reimbursement if Medicare reverses its initial denial.

In-Home Doctor Services

Medicare can cover in-home doctor visits when deemed medically necessary. This is often the case for:

• Homebound individuals

• Patients receiving palliative or hospice care

• Post-surgical follow-up care

Coverage is similar to outpatient doctor services, including the 20% coinsurance. The doctor must be enrolled in Medicare and provide services within Medicare’s coverage guidelines.

Don’t Assume Every Service Is Covered

Even when you see a doctor who accepts Medicare, not all services may be covered. You might be asked to sign an Advance Beneficiary Notice (ABN), which lets you know a particular service may not be covered.

If you sign the ABN and still receive the service, you could be responsible for the full cost. If you don’t sign it, and the doctor proceeds anyway, you may not be liable. Understanding this form is critical before receiving non-covered services.

Always Review Your Medicare Summary Notice

You receive a Medicare Summary Notice (MSN) every quarter if you’ve received medical services. It details:

• What was billed

• What Medicare paid

• What you owe

Reviewing your MSN helps you catch billing errors or services you didn’t receive. If anything looks wrong, you can contact Medicare or file a formal appeal.

Staying Informed Helps You Save

With doctor visits being such a routine part of care, understanding how Medicare handles them in 2025 helps you stay financially prepared and informed. Whether you’re scheduling preventive care or managing a chronic condition, small knowledge gaps can lead to big expenses.

Get the Right Advice Before Your Next Appointment

Doctor coverage under Medicare may seem simple on the surface, but the fine print often catches people off guard. Make sure you understand how assignment works, what your plan pays for, and when you’re responsible for coinsurance or deductibles. If you’re still unsure, speak to a licensed agent listed on this website to get expert help tailored to your situation.