I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?

Question

Melonie Wood · Accepted Answer

Even with Medicare, specialist visits can cost money due to deductibles, coinsurance, and potential charges from non-participating providers. Medicare typically covers 80% of the Medicare-approved amount for most services, meaning you'll need to pay the remaining 20% (coinsurance) after meeting your deductible. Additionally, if your specialist doesn't accept Medicare assignment, they may charge you more than the Medicare-approved amount.

Answered by Melonie Wood on April 21, 2025

Agent Licensed in FL & AL

Answered by Melonie Wood Medicare Insurance Agent

Bill Green · Answer

That’s a great question, and one we hear a lot. Even though you’ve paid into Medicare through payroll taxes, that mainly covers Part A, which is hospital insurance—not everything. Part B, which covers outpatient care like specialist visits, has its own monthly premium and usually only covers 80% of the cost after you meet the deductible. That means you’re responsible for the remaining 20%, and there’s no out-of-pocket max unless you have additional coverage. This is where a Medicare Advantage or Supplement plan can help reduce or cap those costs. It’s frustrating, but you're not alone—Medicare can feel like a maze, and that's why it's worth reviewing your options to see what might lower your expenses moving forward.

Answered by Bill Green on March 26, 2025

Broker Licensed in FL, AL, AZ & 19 other states

Answered by Bill Green Medicare Insurance Agent

Jolynn Allen · Answer

It depends - if you are on Original Medicare you would have your Part B annual deductible and then 20%. If you have enrolled in a Medicare Advantage plan the amount you pay would be based on the specialist copay which can varies per plan. I would need to know what plan you are enrolled in to answer your question.

Answered by Jolynn Allen on April 7, 2025

Agent Licensed in CO

Answered by Jolynn Allen Medicare Insurance Agent

Norman Smith · Answer

I think we need to clarify what “Medicare” you actually have!
People say they have Medicare when they actually have a Medicare Advantage plan, which is NOT MEDICARE, and too often then not, is NOT AN ADVANTAGE!!!

Original Medicare through your Part B would allow you the freedom to choose your specialist and would cover 80% of the cost. If you had a Supplement plan with Original Medicare, they could be paying for some or ALL of those charges and excess charges.

My recommendation is to speak to a Medicare professional so that during Open Enrollment, starting October 15th, you can assure you find the correct plan you need!

Diana Garner · Answer

What you paid in all those years covered Medicare Part A premiums. When you retire, Medicare Part A is free if you worked for the last 10 years. Medicare Part B will have a premium that you will pay.

Your costs for specialist visits are likely because of deductibles, coinsurance, copays, or even the fact that you are seeing an out-of-network doctor.

If you are ONLY covered by Medicare Part A and B, Medicare Part B covers doctor's services, but it has a deductible and coinsurance. 

If you are covered by Medicare Part A, Part B, and a Medicare Supplement, it will depend on what supplement you are covered by. Plan F has no copays, coinsurance, or deductible. Plan G has a small deductible to meet, then it will cover everything 100% for the rest of the year. Other plans will have deductibles and coinsurance.

If you are covered by Medicare Part A, Part B, and a Medicare Advantage plan, there will be copays that you must pay until you reach the maximum out-of-pocket limit on the plan. Depending on where you live and what plan you are covered by, that maximum out-of-pocket can range anywhere from $2,000 up to $10,000.

There is also the issue that your specialist may not accept Medicare assignment (they agree to bill Medicare directly), so they charge you more (15%) than the Medicare-approved amount, which leads to a balance you have to pay.

Diana Salisbury · Answer

If you have a supplement, such as a plan G, you must meet your 2025 deductible first - which is $257 this year.  If you have original Medicare you will pay the 20% that Medicare didn't cover.

Valentina Gatewood · Answer

Lets do a product review and make sure you are on the correct plan. Maybe we can find a better solution for you, or it might be your specialist are out of network. However lets find out how we can assist you.

Answered by Valentina Gatewood on April 8, 2025

Broker Licensed in CA, AZ, ID & NJ

Answered by Valentina Gatewood Medicare Insurance Agent

Peter Yeh · Answer

You can get the lowest cost if your doctor accepts the Medicare-approved amount as full payment for a covered service. This is called “accepting assignment.

Glenn Quinn · Answer

Are you on Original Medicare or an Advantage plan.
Original Medicare only pays 80% of provider services. Most Advantage plans have copays.

I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?

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I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?

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