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

Bill Green · Accepted 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

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!

Gary Church · Answer

If you're on Original Medicare Part B, you have a deductible that has to be met, which for 2025 is $257.00. Also, if seeing a specialist, does that specialist accept Medicare.

Melonie Wood · 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

Misty Bolt · Answer

How much is your specialist copays. What city and state do you live in and I can try to find you a lower copay.

Ben Washington · Answer

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? Medicare-approved amount for medically necessary services, which includes specialist visits. Medicare covers the remaining 80%. So cost is more specialist service is typically higher

Answered by Ben Washington on June 16, 2025

Broker Licensed in IL, FL, MN, SC, TX & WI

Answered by Ben Washington 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

Steven Bleicher · Answer

As long as you have both Part A and Part B in place, it covers 80% of your cost. In addition, you must have either a Medigap or an Advantage plan, the former of which pays all of the remaining 20% and the latter paying “some” of the balance. But, if you have a Part C HMO Advantage plan and see a doctor who is not in your network, you will pay extra money for the visit. But, there is also an Advantage plan called a PPO plan, where you are entitled to visit both in and out of network doctors, at your discretion. Lastly, I trust that you know that a “concierge” doctor will be THE most expensive doctor you can see since they usually don’t accept anything that is Medicare-based.

Answered by Steven Bleicher on June 20, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

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

Alan &quot;AL&quot; Minthorn · Answer

Medicare’s cost sharing is independent of your contributions through payroll deductions, or premiums paid. Specialist visits are expensive due to their expertise you’re accessing. You might review your current plan options with a good agent to see what other options may be available.

Answered by Alan "AL" Minthorn on June 1, 2025

Broker Licensed in ME, FL, GA, NC & NH

Answered by Alan "AL" Minthorn 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.

Michael Braden · Answer

Many people mistaken belief Medicare is free.  Medicare is a wonderful health plan, but it is not free.  In 2025 Medicare Part B costs a minimum of $187 per month. The rest dependfs on whether you are drawm tp Medicare Advantage plans or to Medicare Supplememnt plans

You must be enrolled in Part B to enroll in any Medicare Advantage or Medicare Supplement plan.

You cannot enroll in both Original Medicare and in Medicare Advantage.

There are co-pays and co-insurance with MA and MAPD plans.

Medicare Advantage plans are tricky, so it is absoutely important taht you dtudy teh Expplanation Of Benefitsa section for any plan you are considering.This is where INsurance companies like to put all of the "Fine Print".

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.

Fred Manas · Answer

Here's a breakdown of why this might be happening:
1. Medicare Part B Deductible and Coinsurance: Deductible: Medicare Part B, which covers specialist visits, has an annual deductible. This means you pay a certain amount out-of-pocket before Medicare starts covering the costs. In 2025, the Part B deductible is $257.
Coinsurance: After you've met your deductible, you are typically responsible for a 20% coinsurance for most medically necessary services, including specialist visits. Medicare pays the remaining 80%. For example, if a specialist visit costs $100 after you've met your deductible, Medicare would pay $80, and you would be responsible for the remaining $20. 
2. Provider Acceptance of Medicare Assignment: Accepting Assignment: Doctors and specialists who "accept assignment" agree to accept the Medicare-approved amount as the full payment for their services. This means they won't bill you for more than the appropriate deductible and/or cost-sharing amount. Not Accepting Assignment: If your specialist doesn't accept Medicare assignment, they may "balance bill" you. This means they can charge you the difference between their fee and the Medicare-approved amount. It's crucial to check with your specialist beforehand to ensure they accept Medicare assignment. 
3. Medicare Advantage Plans: Varying Costs: If you have a Medicare Advantage plan (Part C), your out-of-pocket costs, including those for specialist visits, can vary depending on the specific plan. Network Restrictions: Many Medicare Advantage plans require you to see specialists within their network to receive full benefits. Copays: Medicare Advantage plans may have fixed copayments for specialist visits, and these costs are factored into the plan's overall out-of-pocket maximum. 
4. Other Factors: Medically Necessary vs. Preventive Services: Medicare Part B cover some of the costs not covered by Original Medicare.

Vachik Chakhbazian · Answer

While Original Medicare covers medically necessary specialist visits, you'll generally be responsible for the Part B deductible and 20% coinsurance for the Medicare-approved amount of the service.

Andrew Kramer · Answer

That you paid into Medicare for years has no relation to either the co-insurance (20%) on original Medicare, or the co-pay on an Advantage plan, that you pay for specialist visits. Those costs don't just decrease according to you paying for Medicare!

Answered by Andrew Kramer on June 13, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Russell Scott · Answer

The length of time having Medicare doesn't impact your costs on utilization. Specialist visits are billed under Part B of Medicare. There is an annual deductible as well as 20% coinsurance on Part B charges that Medicare beneficiaries are subject to pay. There are other insurance policies such as medigap plans that can help with these costs.

Answered by Russell Scott on June 16, 2025

Agent Licensed in OK, MO & TX

Answered by Russell Scott Medicare Insurance Agent

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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