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1. Medicare Copays For Office Visits
2. Medicare Copay For Doctor Visit
3. What Copay For Doctor Visits
4. In Home Doctor Visits Medicare
5. What Is The Copay For A Doctor Visit With Medicare

When Beverly Dunn called her new primary care doctor’s office last November to schedule an annual checkup, she assumed her Medicare coverage would pick up most of the tab.

States can impose copayments, coinsurance, deductibles, and other similar charges on most Medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income. All out of pocket charges are based on the individual state’s payment for that service. Copays for Medical Assistance and General Assistance members Medicaid members 18 years of age and older and in the Medical Assistance or General Assistance categories will have to pay a copay for prescriptions and various medical services. Members who are under the age of 18, pregnant, or in a nursing home do not have to pay the copays. If your Medicaid is with your LDSS, to order a new Medicaid Benefit Identification Card, please call or visit your local department of social services. If your Medicaid is with the Marketplace (NY State of Health) and you need to order a new benefit card please call the call center at 1-855-355-5777. Members residing in the five boroughs of NYC can call the HRA Infoline at 1 (718) 557-1399.

The appointment seemed like a routine physical, and she was pleased that the doctor spent a lot of time with her.

Until she got the bill: $400.

Dunn, 69, called the doctor’s office assuming there was a billing error. But it was no mistake, she was told. Medicare does not cover an annual physical exam.

Dunn, of Austin, Texas, was tripped up by Medicare’s confusing coverage rules. Federal law prohibits the health care program from paying for annual physicals, and patients who get them may be on the hook for the entire amount. But beneficiaries pay nothing for an “annual wellness visit,” which the program covers in full as a preventive service.

“It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’” said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”

An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure.

The focus of the Medicare wellness visit is on preventing disease and disability by coming up with a “personalized prevention plan” for future medical issues based on the beneficiary’s health and risk factors.

At their first wellness visit, patients will often fill out a risk-assessment questionnaire and review their family and personal medical history with their doctor, a nurse practitioner or physician assistant. The clinician will typically create a schedule for the next decade of mammograms, colonoscopies and other screenings and evaluate people for cognitive problems and depression as well as their risk of falls and other safety issues.

They may also talk about advance care planning with beneficiaries to make decisions about what type of medical treatment they want in the future if they can’t make decisions for themselves.

At subsequent annual wellness visits, the doctor and patient will review these issues and check basic measurements. Beneficiaries can also receive other covered preventive services such as flu shots at those visits without charge.

When the Medicare program was established more than 50 years ago, its purpose was to cover the diagnosis and treatment of illness and injury in older people. Preventive services were generally not covered, and routine physical checkups were explicitly excluded, along with routine foot and dental care, eyeglasses and hearing aids.

Over the years, preventive services have gradually been added to the program, and the Affordable Care Act established coverage of the annual wellness visit. Medicare beneficiaries pay nothing as long as their doctor accepts Medicare.

However, if a wellness visit veers beyond the bounds of the specific covered preventive services into diagnosis or treatment — whether at the urging of the doctor or the patient — Medicare beneficiaries will typically owe a copay or other charges. (This can be an issue when people in private plans get preventive care, too. And it can affect patients of all ages. The ACA requires insurers to provide coverage, without a copay, for a range of preventive services, including immunizations. But if a visit goes beyond prevention, the patient may encounter charges.)

And to add more confusion, Medicare beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year of joining Medicare Part B, which covers physician services.

Meanwhile, some Medicare Advantage plans cover annual physicals for their members free of charge.

Many patients want their doctor to evaluate or treat chronic conditions like diabetes or arthritis at the wellness visit, said Dr. Michael Munger, who chairs the board of the American Academy of Family Physicians. But Medicare generally won’t cover lab work, such as cholesterol screening, unless it’s tied to a specific medical condition.

At Munger’s practice in Overland Park, Kan., staffers routinely ask patients who come in for a wellness visit to sign an “advance beneficiary notice of noncoverage” acknowledging that they understand Medicare may not pay for some of the services they receive.

As long as beneficiaries understand the coverage rules, it’s not generally a problem, Munger said.

“They don’t want to come back for a separate visit, so they just understand that there may be extra charges,” he said.

Medicare Copays For Office Visits

Beneficiaries may not be the only ones who are unclear about what an annual wellness visit involves, said Munger. Providers may be put off if they think that it’s just another task that adds to their paperwork.

A recent study published in the journal Health Affairs found that in 2015 just over half of practices with eligible Medicare patients didn’t offer the annual wellness visit. That year, 18.8 percent of eligible beneficiaries received an annual wellness visit, the analysis found.

Primary care physicians generally want to see their patients at least once a year, Munger said, but it needn’t be for a complete physical exam.

A wellness visit or even a visit for a sprained ankle could give doctors an opportunity to check in with patients and make sure they’re on track with preventive and other care, Munger said.

When Dunn called the doctor’s office about the $400 bill, she said, the staff told her she had signed papers agreeing to pay whatever Medicare didn’t cover.

Dunn doesn’t dispute that.

“There were lots of papers that I signed,” she said. “But nobody told me I would get a bill for $400. I would remember that.”

In the end, the clinic waived all but $100 of the charge, but warned her that next year she’ll have to pay $300 if she wants an annual physical with that doctor. If she comes in just for an annual wellness visit, she’ll be seen by a physician assistant.

Dunn is considering her options. She would like to stay with her new doctor, who came highly recommended, and she’s worried she might have trouble finding another one just as good who accepts Medicare. But $300 seems steep to her for a checkup.

“This whole thing was so stressful for me,” she said. “I lost sleep for nights. It’s not that I couldn’t afford it, but it didn’t seem right.”

Copays for Medical Assistance and General Assistance members

Medicaid members 18 years of age and older and in the Medical Assistance or General Assistance categories will have to pay a copay for prescriptions and various medical services.

Members who are under the age of 18, pregnant, or in a nursing home do not have to pay the copays.

Medicare Copay For Doctor Visit

Residents of a long-term care facility or other medical institution, including intermediate care facilities, do not pay copays.

MA recipients, regardless of age, who qualify for benefits under Title IV-B Foster Care and Title IV-E Foster Care and Adoption Assistance do not pay copays.

PCP visits never have a copay.

Medical and General Assistance recipients cannot be denied a prescription if they cannot afford a copayment. If you cannot afford your prescription copayment, please let your pharmacist know. If you have any problems getting your medication from the pharmacist, please contact Member Relations at 1-800-553-0784 or 215-849-9600 (TTY 1-877-454-8477).

Medical Assistance copays

For the following services you will pay $5.00:

• For acupuncture, you will pay $5.00 for each visit (up to 20 visits). Members who are pregnant or under age 21 do not need to pay a copay.

What Copay For Doctor Visits

For the following services you will pay $3.00:

• For inpatient hospital care (which includes both general and medical rehabilitation hospitals), you will pay $3.00 for each day you are in the hospital up to $21.00 for the stay
• For Short Procedure Unit (SPU)/Ambulatory Surgical Center (ASC) visits, you will pay $3.00 per admission or visit.
• For brand name prescription drugs, you will pay $3.00 for each prescription or refill.

For the following services, you will pay $1.00:

• For outpatient x-ray services, you will pay $1.00 for the service (not for each x-ray).
• For generic prescription drugs, you will pay $1.00 for each prescription or refill.
• For chiropractor visits, you will pay $1.00 for each visit.

In Home Doctor Visits Medicare

You don’t have to pay a copayment for any of the following if they are part of your benefit package:

What Is The Copay For A Doctor Visit With Medicare

• Any services provided in an emergency
• Birth centers
• Blood and blood products
• Certain drugs for high blood pressure, cancer, diabetes, asthma, epilepsy, heart disease, psychosis, HIV/AIDS, glaucoma, depression, and anxiety, as well as anti-Parkinson agents, anti-manic agents, anti-convulsants, anti-neoplastic agents, oral contraceptives, test strips, lancets, meters, and needles
• CRNP (Certified Registered Nurse Practitioner) services
• Dental visits
• Disposable medical supplies
• Doctor's fee for x-rays, diagnostic tests, nuclear medicine or radiation therapy
• Drugs and vaccines that you get in your doctor’s office
• Family planning services
• Home health agency services
• Hospice services
• Laboratory tests
• Medical examinations for members under age 21 provided through the EPSDT program More than one of a series of specific allergy tests provided in a 24-hour period Non-emergency ambulance services
• Nurse midwife (maternity services)
• Optometrist visits
• Oxygen
• Physician visits
• Podiatrist visits
• Portable x-ray services
• Renal dialysis services
• Rental of Durable Medical Equipment (DME)
• Skilled Nursing Facility
• Targeted case management services
• Tobacco cessation counseling services
• Waiver services