Original Medicare (Parts A & B): Doctor and Other Healthcare Provider Services

Several physician/practitioner services are covered and include facility, office, telehealth (virtual), and in-home visits.

Covered services

Medically necessary medical care or surgery services furnished in a physician’s office, certified ambulatory surgical center, hospital outpatient department, or any other location.

Consultation, diagnosis, and treatment by a specialist.

Basic hearing and balance exams performed by a specialist, if ordered by a doctor to determine the need for medical treatment.

Certain telehealth services, including consultation, diagnosis, and treatment by a physician or practitioner:

• There is the option of getting these services through an in-person visit or by telehealth. If telehealth services are chosen, they must be with a network provider who offers the service by telehealth.

• Please see the Telehealth benefits for more information.

Telehealth services for monthly end-stage renal disease-related visits for home dialysis members in a hospital-based or critical access hospital-based renal dialysis center, renal dialysis facility, or the member’s home.

Telehealth services for members with a substance use disorder or co-occurring mental health disorder, regardless of their location.

Telehealth services for diagnosis, evaluation, and treatment of mental health disorders if:

• There was an in-person visit within 6 months prior to the first telehealth visit

• There is an in-person visit every 12 months while receiving these telehealth services

• Exceptions can be made to the above for certain circumstances

Virtual check-ins (for example, by phone or video chat) with the doctor for 5–10 minutes if:

• Not a new patient and

• Check-in isn’t related to an office visit in the past 7 days and

• Check-in doesn’t lead to an office visit within 24 hours or the soonest available appointment

Evaluation of video and/or images sent to the doctor, and interpretation and follow-up by the doctor within 24 hours if:

• Not a new patient and

• Evaluation isn’t related to an office visit in the past 7 days and

• Evaluation doesn’t lead to an office visit within 24 hours or the soonest available appointment

Consultation the doctor has with other doctors by phone, internet, or electronic health record.

Second opinion by another participating network provider prior to surgery.

Non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician).

Rural Health Clinic services

Rural health clinics provide many outpatient primary care and preventive health services in rural and underserved areas.

Federally Qualified Health Center services

Federally qualified health center services provide many outpatient primary care and preventive health services. All Federally Qualified Health Centers may offer discounts if your loved one's income is limited.

Click here to find a health center near your loved one.

New patient status

If your loved one hasn't received services from their provider or group practice in the last 3 years, the provider may consider them a new patient. Be sure to check with the provider or group practice about your loved one's status and find out if the provider is accepting new patients.