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Doctor visits can be stressful for seniors on Original Medicare, Part A and Part B. Read on for tips about planning doctor visits so you’ll know what to expect and have the information you need to enjoy a smooth, stress-free doctor visit.
Some useful information to bring to doctor visits — especially if it’s your first visit with this doctor — includes:
Most medical practices keep this information in your medical record so you won’t have to bring it again.
When planning your doctor visit, you should ask your doctor ahead of time if he or she accepts Medicare assignment. Assignment means that your doctor has an agreement with Medicare to accept the Medicare-approved amount for doctor visits as full payment. This means that you’ll only have to pay 20% of the Medicare-approved amount for each doctor’s visit (this is called coinsurance) after any deductible amount if applicable.
If you have a non-participating doctor, meaning that he or she doesn’t routinely accept Medicare assignment, you will generally have to pay the 20% coinsurance plus up to 15% of the cost of the visit after the deductible amount if applicable. This extra 15% if called a limiting charge, and it varies depending on which U.S. state you live in. Altogether, you will have to pay up to 35% of the cost of the visit if you choose a non-participating doctor.
If you go to a doctor that’s not enrolled with Medicare at all, you’ll typically have to pay 100% of the cost of the visit and services, and you won’t be eligible to receive any Medicare coverage.
When planning your doctor visit, you can visit Physician Compare online to find out ahead of time if your doctor accepts Medicare assignment. You can also visit MyMedicare.gov, which offers direct access to your preventive health information, including detailed information about the free services, tests, and screenings for which you’re eligible under Medicare
Some Medicare Advantage plans may require prior authorization for certain services and supplies. If your doctor requests such a service or item from your health plan for you, the health plan sends its approval (or denial). For example, some Medicare Advantage plans require prior authorization of certain prescription drugs before you can use them.
Some Medicare plans offered by private Medicare-approved insurance companies, such as Medicare Advantage or Medicare Supplement (Medigap) plans, require you to get a referral before you see a specialist. If you have a health condition that you think could benefit from a specialist, ask your primary care physician for a referral.
If you’re enrolled in Original Medicare, Part A and Part B, you generally don’t need a referral to see a Medicare-participating specialist.
Doctor visits for beneficiaries are covered under Medicare Part B (medical insurance). If you’re enrolled in a Medicare Advantage plan (Medicare Part C), your doctor visits are covered as well, since Medicare Advantage plans are required to give you at least the same coverage as Original Medicare, Part A and Part B. However, some costs may still apply, as described below.
Original Medicare, Part A and Part B:
Medicare Part C (Medicare Advantage):
Medicare Advantage plans are optional, and offered by private health insurers. They’re required to provide at least the same coverage as Original Medicare, but they can set their own monthly premiums and other costs, like coinsurance, copayments, and deductibles. Many of these plans include prescription drug coverage. In some cases, depending on your health-care needs, Medicare Advantage plans can save you money.
If you have a Medicare Advantage plan, refer to your plan policy for information on the copayment and other costs for doctor visits.
Medigap (Medicare Supplement) plans:
Medigap plans are also optional, and sold by private health insurance companies. Each company sets its own premium, although the plans are standardized in terms of coverage within each lettered category. You still need to pay your Part B premium (and Part A, if applicable). Medigap plans might help with Original Medicare costs, like copayments, coinsurance, and deductibles.
During the first 12 months that you’ve been enrolled in Medicare Part B, you can have a free “Welcome to Medicare” visit with your Medicare-participating health-care provider. Besides reviewing your overall health and medical history, your provider can order certain health screenings, such as an electrocardiogram (EKG), if you need them.
Once a year after the Welcome to Medicare visit (as long as you’re still enrolled in Part B), you can have a free “Wellness” visit. Your provider will ask you questions about your health, and develop a customized prevention plan for you. He or she can order health screenings, such as the EKG mentioned above, if you need them.
If your doctor orders tests that aren’t covered under the Medicare “Wellness” or “Welcome to Medicare” visits, you might have to pay coinsurance, and the Part B deductible might apply.
Your benefits as a Medicare beneficiary include many free preventive screenings and services (covered under Medicare Part B). These free benefits include, but are not limited to: bone mass measurements, cardiovascular disease screenings, colorectal cancer screenings, diabetes screening, glaucoma tests, HIV testing, prostate cancer screenings, flu shots, and Hepatitis B shots.
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