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Medicare Doctor Coverage (Part B)

Table of Contents

Summary: Medicare Part B provides coverage for doctors visits, outpatient care, preventative services, and durable medical equipment. In this article, we’ll explain each service that Medicare Part B covers and the out-of-pocket costs you’ll be responsible for. Estimated Read Time: 7 min

What is Covered by Medicare Part B?

Medicare Part B is the outpatient medical insurance portion of Original Medicare. It helps pay for preventative services as well as medically necessary outpatient services such as doctors visits, physical therapy, ambulance services, and more. Medicare Part B also provides coverage for durable medical equipment such as wheelchairs, walkers, insulin pumps, and other equipment deemed medically necessary.

When you use your Medicare Part B coverage, your out-of-pocket costs will include your annual deductible and any coinsurance or copayments. You will be responsible for paying all costs until you meet your Medicare Part B deductible. After meeting your deductible, Medicare will typically cover 80% of costs for covered services and you will end up paying a 20% coinsurance. There are some services, such as the COVID-19 vaccine, that are fully covered by Medicare and are available at no cost to you.

Medicare Part B Coverage Summary and Comparison Chart

Preventative Services Covered by Medicare Part B

In addition to covering outpatient care, Medicare Part B also covers preventative services. Medicare defines preventative services as “health care to prevent illness or detect illness at an early stage, when treatment is likely to work best”. You will not have out-of-pocket costs when receiving most preventative services from healthcare providers who accept Medicare assignment.

Medicare Part B covers preventative services such as:

  • Diabetes screenings
  • Mammograms
  • Prostate cancer screenings
  • Depression screenings
  • Tobacco use cessation counseling
  • Certain vaccines

If you receive a preventative service at a doctor’s office or other healthcare facility that does not accept Medicare assignment, you could end up paying excess charges for your service. You can call the office ahead of time to ensure they accept assignment before making your appointment.

Welcome to Medicare Preventative Visit

During the first 12 months of having Medicare Part B, you can schedule a “Welcome to Medicare” preventative visit, also known as the Initial Preventative Physical Exam (IPPE). During this exam, your doctor will review your medical history and provide education on preventative services. You’re only allowed one “Welcome to Medicare” visit in your lifetime and it is fully covered by Medicare if your healthcare provider accepts assignment.

Though your “Welcome to Medicare” visit can be valuable for assessing your overall health, it is not mandatory; you do not need to have your Welcome to Medicare visit to qualify for annual wellness visits.

Annual Wellness Visit

Another preventative service that is covered by Medicare Part B is a yearly “wellness” visit. Wellness visits are not the same as a routine physical exam. These visits are an opportunity for you to fill out or update your “Health Risk Assessment” and develop or discuss a personalized plan to prevent disease or disability with your doctor.

Annual wellness visits are covered once every 12 months. You cannot receive your first wellness visit until 12 months after the start of your Medicare Part B coverage or 12 months after your “Welcome to Medicare” visit.

If during your wellness visit your doctor recommends tests or services outside of what is typically included in a wellness visit, you may be responsible for out-of-pocket costs.

Medicare Part B Vaccine Coverage

Medicare Part B provides coverage for certain vaccines at no cost to you when you use a provider who accepts assignment.

Vaccines that Medicare Part B Covers:

  • Seasonal flu
  • Hepatitis B (if you’re at medium or high risk)
  • Pneumococcal
  • COVID-19

Medicare covers the flu shot once per flu season (or more if deemed medically necessary). Hepatitis B shots are covered for individuals who are deemed to be at medium or high risk for Hepatitis B. The pneumococcal vaccine, which helps protect against bacteria that causes pneumonia, is covered by Medicare once in your lifetime.

COVID-19 vaccines continue to be fully covered by Medicare. You will not need to pay any out-of-pocket costs for receiving the updated (2023-2024 formula) Moderna or Pfizer-BioNTech COVID-19 vaccine. Make sure to bring your Medicare card with you when receiving your vaccine so your doctor or pharmacy can bill Medicare.

Vaccines and other recommended adult immunizations that are not covered by Medicare Part B:

  • Shingles
  • Tetanus
  • Diphtheria
  • Pertussis

These shots are instead covered under your Medicare Part D Prescription Drug plan. Whether you have a standalone Medicare Part D plan or have drug coverage through a Medicare Advantage plan, you can contact your plan for more information on adult immunizations that are covered.

Outpatient Care Covered by Medicare Part B

Medicare Part B provides coverage for outpatient care and services. Though Medicare Part A provides hospital coverage, your Medicare Part B will cover any services you get as a hospital outpatient. Knowing whether you are an inpatient or outpatient at a hospital is important for understanding what costs you are going to be responsible for.

When using your Medicare Part B coverage in a hospital outpatient setting, you will pay a 20% coinsurance for the provider’s service after meeting your Medicare Part B deductible. Additionally, you typically pay a copayment to the hospital for each service you receive in a hospital outpatient setting.

Sometimes it can be confusing when trying to figure out if you’re an inpatient or outpatient. For example, if you go to the ER, you are considered an outpatient until you are formally admitted as an inpatient. If you’re unsure whether you are an inpatient, check with whoever is providing your healthcare services.

Medicare Part B covers outpatient care including:

  • Emergency and observation services
  • Lab tests billed by the hospital (blood tests, urinalysis, etc.)
  • X-rays and other radiology services billed by the hospital
  • Medical supplies
  • Outpatient surgeries
  • Physical and occupational therapy services
  • Drugs that you get as part of your outpatient service or procedure (like certain injectable drugs)

*For a full list of Medicare Part B-covered services, visit Medicare.gov.

Medicare Part B Coverage for Durable Medical Equipment

Durable Medical Equipment (DME), such as walkers, wheelchairs, or oxygen equipment, are covered by Medicare Part B when deemed medically necessary. Medicare defines durable medical equipment as equipment that can withstand repeated use, is used for a medical reason, is used in your home, and is expected to last at least 3 years.

Examples of Durable Medical Equipment Covered by Medicare Part B:

  • Blood sugar meters
  • Continuous Positive Airway Pressure (CPAP) machines
  • Hospital beds
  • Oxygen equipment
  • Wheelchairs & scooters
  • Patient lifts

After meeting your deductible, you will need to pay a 20% coinsurance for any durable medical equipment that is covered under Medicare Part B. Before purchasing or renting your equipment, make sure the equipment supplier participates in Medicare and accepts assignment; otherwise, there’s no limit to how much they can charge you for your equipment.

Medicare Part B Coverage Changes for 2024

In 2024, Medicare will cover more services related to mental health care. Starting January 1st, 2024, Medicare will cover mental health care services provided by marriage & family therapists and mental health counselors. Also starting in 2024, Medicare will cover intensive outpatient program services that are provided by hospitals, community mental health centers, federally qualified health centers, and rural health clinics.

Telehealth visits from any location, including your home, will continue to be covered by Medicare through the end of 2024. In 2025, you will need to be in an office on medical facility located in a rural area to get most telehealth services. There are certain Medicare telehealth services you can continue to receive without being in a rural healthcare setting. These services include:

  • Monthly End-Stage Renal Disease (ESRD) visits for home dialysis
  • Diagnosis, evaluation, or treatment of symptoms of an acute stroke
  • Services related to treating a substance use disorder or a co-occurring mental health disorder
  • Services related to diagnosing, evaluating, or treating a mental health disorder
  • Behavior health services

The changes to insulin coverage for Medicare enrollees that went into effect in 2023 will continue into 2024. For those who use an insulin pump that is covered under Medicare Part B’s durable medical equipment benefit, your cost for a monthly supply of insulin for your pump cannot exceed $35. Your Medicare Part B deductible does not apply, which means you do not have to meet your deductible before Medicare pays its portion for your Part B-covered insulin. Please note that regular injectable insulin, such as insulin pens, are covered under Medicare Part D; only insulin pumps are covered under Medicare Part B.

How to Get Coverage for Services Medicare Part B Doesn’t Cover

There are many services that Medicare Part B does not cover such as dental, vision, hearing, and prescription drugs. However, there are supplemental coverage options available for those who want additional coverage outside of Original Medicare.

Have questions about Medicare Part B coverage? We can help! Give us a call at the number above to speak to one of our licensed insurance agents. You can also learn more about applying for Medicare Part B by checking out our links below.

Apply for Medicare Part B

Ready to get Medicare Part B coverage? Learn more about signing up for Part B here.

Medicare Part B Coinsurance

Most Medicare Part B covered services have a 20% coinsurance. Learn more here.

Medicare Coverage

Didn’t see a service you were looking for? Get a general overview of Medicare coverage here.

Sources

What does Part B of Medicare (Medical Insurance) Cover, U.S. Department of Health and Human Services. Accessed October 2023

https://www.hhs.gov/answers/medicare-and-medicaid/what-does-medicare-part-b-cover/index.html

Medicare Wellness Visits, CMS Medicare Learning Network. Accessed October 2023

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html

Medicare & You 2024, Medicare. Accessed October 2023

https://www.medicare.gov/publications/10050-Medicare-and-You.pdf

Allison Auvil

Allison Auvil

Content Strategist
Allison Auvil is a Content Strategist at Elite Insurance Partners. With a bachelor’s degree in visual arts, Allison brings a creative perspective to her writing. She has been involved in content writing and editing for the past five years. The combination of an extensive Medicare101 training program and daily thorough research has made Allison a Medicare Guru. A detail-oriented writer, Allison is focused on writing pieces that are accurate, informative, and easy to read. She begins her writing process with meticulous research and note taking. Once her data is compiled, Allison enjoys the challenge of taking complex data and information and creating articles that are easy to understand.
Ashlee Zareczny

Ashlee Zareczny

Compliance Supervisor and Licensed Medicare Agent
Ashlee Zareczny is the Compliance Supervisor for ApplyforMedicare. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.
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