Paul Sanchez
Health insurance in the USA can be complicated, with many pitfalls to be aware of. Generally, health insurance covers most doctor and hospital visits, prescription drugs, wellness care, and medical devices. However, there are many different types of insurance, and each insurance company has different rules for using healthcare benefits. For example, Medicare Part B covers 80% of the cost of medically necessary doctor visits, but individuals must pay the remaining 20% as coinsurance. It's important to understand your insurance plan's benefits and limitations, especially as you may be required to receive care from certain doctors and hospitals.
| Characteristics | Values |
|---|---|
| Cost-sharing | You're responsible for some of the cost of a medical item or service when using insurance. This can take the form of a copayment, deductible, or coinsurance. |
| Medicare | A federally funded insurance plan for US citizens aged 65 and older. Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. |
| Preventative care | Most health plans are required to cover preventive care without any cost-sharing. |
| Insurance network | Doctors and hospitals often contract with insurance companies to become part of their "network". If you go to a doctor in your insurance company's network, you will pay less out of your own pocket. |
| Ambulance services | Ground ambulance services are not covered by billing protections in the No Surprises Act and can charge out-of-network rates. |
| Emergency room visits | You can always get treatment at an emergency room, but it may cost more than a doctor's office or an urgent care clinic. |
| Out-of-network charges | You're protected from out-of-network charges when you get care related to a visit to an in-network hospital or outpatient surgery center. |
| Diagnostic tests | Whether a diagnostic test is covered by insurance depends on the specific test and insurance policy. |
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What You'll Learn
Medicare Part B and C cover doctor visits
In the United States, health insurance typically covers most doctor and hospital visits, prescription drugs, wellness care, and medical devices. However, there may be instances where certain services or treatments are not covered by insurance, and individuals may be responsible for out-of-pocket expenses.
Medicare is a federally funded insurance plan in the United States, primarily covering citizens aged 65 and older, as well as younger individuals with specific medical conditions or disabilities. It consists of several parts, including Part A, Part B, Part C, and Part D, each covering different medical expenses.
Medicare Part B and Medicare Advantage (Part C) cover doctor visits, but there may be additional costs. Part B covers two types of services: medically necessary and preventive. Medically necessary services are used to diagnose and treat medical conditions, while preventive care helps prevent or detect illnesses early on. Part B covers 80% of the Medicare-approved cost for medically necessary doctor visits, and individuals pay the remaining 20% as coinsurance. Preventive services under Part B include annual wellness visits and various screenings, and individuals typically pay nothing for these services if the healthcare provider accepts assignment.
Medicare Advantage (Part C) is an alternative to Original Medicare, offered by private insurance companies. These plans must provide at least the same level of coverage as Original Medicare, including doctor visits. However, individuals may need to pay coinsurance and meet deductibles, and costs can vary by plan. It's important to note that Medicare Advantage plans may have different rules and restrictions on which doctors or facilities can be used.
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Insurers may not cover new technology
In the United States, Medicare is a federally funded insurance plan for citizens aged 65 and older. Younger people with end-stage kidney disease, amyotrophic lateral sclerosis, or certain disabilities are also eligible. Medicare is the basis for the design of all health insurance benefit plans, and many commercial health insurance plans model their basic benefits on those granted to Medicare recipients.
Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits, with the individual paying the remaining 20% as coinsurance. However, Medicare is not an early adopter of new technology, and other insurance plans generally follow its lead. As a result, insurers may not cover new technology until years of evidence of its value versus costs have been gathered.
Insurers may be reluctant to cover new technology due to budgetary reasons or a lack of unanimity regarding its evidence-based character or medical necessity. National health authorities can decide not to cover a new health technology even if it has been acknowledged by health technology assessment centres or covered by insurers in other countries. For example, in Belgium, a national list of medical goods and services covered by mandatory health insurance exists, and reimbursement for new technology can be denied if there are concerns about therapeutic evidence or cost-effectiveness.
In some cases, insurance companies may require doctors to "prove" why a costlier procedure or product is more beneficial than existing alternatives. Partial coverage may be available, where the insurance company pays a specific amount for a procedure, and the patient pays the difference to obtain the new technology. To obtain coverage for a new technology, it is essential to discuss the matter with the insurance company, understand what will be covered, and reach an agreement with the physician regarding the total cost and the patient's financial responsibility.
While some insurance policies have rewarded consumers for healthy behaviors documented by wearable devices, concerns have been raised about the potential negative repercussions of these technologies. Wearables can collect sensitive data on physical activity, calorie intake, blood pressure, and weight, which could be used to penalize policyholders with higher premiums or deny insurance. Therefore, regulations are needed to ensure equal access to devices and prevent health plans from penalizing members based on data collected by wearables.
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Cost-sharing and copayments
In the United States, Medicare is a federally funded insurance plan for citizens aged 65 and older. Younger people with certain disabilities or conditions like end-stage kidney disease or amyotrophic lateral sclerosis are also eligible. Medicare consists of several parts, with Parts A and B making up Original Medicare. Part A covers hospital care, while Part B covers many medical services, including doctor visits, and preventive and medically necessary services. Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare and is administered by private insurance companies.
All health insurance plans require some form of cost-sharing or out-of-pocket expenses, where the insured pays a portion of the costs for covered health care services. Cost-sharing can take the form of copayments, deductibles, or coinsurance. Copayments, also known as copays, are fixed-dollar amounts that insured individuals must pay when receiving certain treatments or services. For example, an enrollee might pay a $10 copayment for a prescription drug, with the insurance plan covering the remaining cost. Copayments are common for prescription drugs and physician visits. Deductibles refer to the amount of money that a person must pay out of pocket before their insurance coverage kicks in. For instance, if a plan has a $1000 deductible, the insured will have to pay the full charge for most medical services until they have spent $1000. After meeting the deductible, the insurance plan will cover a portion of subsequent medical expenses for the rest of the year, with the enrollee paying a share based on copayments and coinsurance. Coinsurance, on the other hand, is a fixed percentage of the allowed amount for a covered item or service that the insured must pay. For example, an enrollee may be required to pay 30% of the allowed amount for lab tests, with the insurance plan covering the remaining 70%.
Medicare Parts B and C both involve cost-sharing components. For Medicare Part B, individuals must pay a deductible, which was $257 in 2025, and a monthly premium of $185. Additionally, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits, with the individual responsible for paying the remaining 20% as coinsurance. Medicare Advantage plans under Part C must provide the same coverage level as Original Medicare, including doctor visits. However, individuals may still need to pay coinsurance and meet deductibles, which vary by plan.
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Preventative care
The Affordable Care Act (ACA) has helped make preventive services more accessible and affordable for all Americans. It requires most health insurance plans to provide coverage without cost-sharing for certain recommended preventive services. This means that insurers cannot charge a copayment, coinsurance, or deductible for these services when delivered by a network provider. The ACA also covers women's preventive healthcare, such as mammograms, cervical cancer screenings, prenatal care, and other services, without cost-sharing. The Women's Preventive Services Initiative (WPSI) provides recommendations for well-woman visits, which can include prenatal, pre-pregnancy, postpartum, and interpartum visits.
Insurers may charge patients for an office visit and preventive service if an out-of-network provider is used when an in-network provider is available. However, if there is no in-network provider able to perform the service, cost-sharing cannot be charged. If a treatment is given as a result of a recommended preventive service but is not the preventive service itself, cost-sharing may be charged in some cases. For example, if a CT scan detects lung cancer, plans may cover the screening but charge for the resulting treatments such as surgery or medication.
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Out-of-network charges
It's important to understand that insurance plans typically do not cover care received from out-of-network providers. However, there may be instances where you unintentionally receive care from an out-of-network provider, such as when visiting an in-network hospital but being treated by an out-of-network physician. In such cases, there are federal and state protections in place to safeguard patients from excessive balance billing.
Before receiving medical care, it is advisable to confirm whether the doctor or facility is within your insurance network. This proactive step can help you avoid unexpected out-of-network charges. Additionally, be cautious when signing any notice and consent forms, as doing so may result in losing your billing protections.
If you encounter a situation where you receive a surprise out-of-network bill, you have the option to request an internal appeal and external review. Contacting your state insurance department or the No Surprises Help Desk can provide you with more information on the appeals process and assist you in resolving unexpected billing issues.
To summarise, out-of-network charges occur when you seek medical care from providers outside of your insurance network, potentially resulting in higher costs. By being diligent about staying in-network and understanding your insurance plan's limitations, you can minimise the risk of unexpected out-of-network charges.
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Frequently asked questions
Yes, most US medical insurers cover visits to the doctor. However, the extent of the coverage depends on the insurance plan and the type of doctor's visit. Some plans may only cover visits to doctors within their network, while others may have different levels of coverage for different types of visits, such as routine check-ups or sick visits.
Medicare Part A covers hospital care, while Medicare Part B covers doctor visits and other medical services. Part B also includes preventive care, which helps prevent illnesses or stop early-stage conditions from progressing.
With Medicare Part B, individuals typically pay 20% of the Medicare-approved cost of medically necessary doctor visits as coinsurance. The Part B deductible, which is $257 in 2025, also applies. Additionally, there is a standard monthly premium of $185.
Yes, Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare. These plans are administered by private insurance companies and must provide the same coverage level as Original Medicare, including coverage for doctor visits. However, costs may vary by plan.
While it is not always required, going to a doctor in your insurance company's network can result in lower out-of-pocket costs. Some insurance plans may not provide any coverage if you do not use a network provider, except in the case of an emergency. Therefore, it is important to consult your insurance plan's network before seeking medical care.
