What Medicare Is and How It Works at Mayo Clinic

Medicare is a federal health insurance program run by the Centers for Medicare & Medicaid Services (CMS). It primarily serves people age 65 and older, though some younger people with disabilities or end-stage renal disease may participate. According to CMS data, more than 66 million Americans were enrolled in Medicare as of 2023. Mayo Clinic is a major healthcare provider that accepts Medicare insurance across its three main locations in Rochester, Minnesota; Jacksonville, Florida; and Phoenix, Arizona, as well as in Mayo Clinic Health System facilities across multiple states.

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Medicare has four main parts. Part A covers hospital insurance, including inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Part B covers medical insurance for outpatient services like doctor visits, preventive care, medical equipment, and laboratory tests. Part D covers prescription drug coverage through private insurance companies approved by Medicare. Part C, also called Medicare Advantage, is an alternative to Original Medicare offered by private insurers that typically includes Parts A, B, and D combined, often with additional benefits like dental or vision coverage.

At Mayo Clinic, Medicare beneficiaries may encounter different coverage scenarios depending on which type of Medicare they have. If a patient has Original Medicare (Parts A and B), Mayo Clinic bills Medicare directly for covered services. If a patient has a Medicare Advantage plan, the private insurance company manages the claims. This distinction matters because it affects which providers are in-network, what cost-sharing applies, and what prior authorization requirements exist. For example, a patient with UnitedHealthcare Medicare Advantage may have different coverage rules than a patient with Humana Medicare Advantage at the same Mayo Clinic location.

Practical takeaway: Before scheduling an appointment at Mayo Clinic, identify which type of Medicare you have by reviewing your Medicare card or calling 1-800-MEDICARE. This information determines how your care will be billed and what your out-of-pocket costs may be.

Original Medicare Coverage at Mayo Clinic

Original Medicare consists of Part A and Part B coverage. Part A is hospital insurance that most people receive automatically when they turn 65, assuming they or their spouse paid Medicare taxes for at least 10 years. Part B is medical insurance that requires monthly premiums, which average about $164.90 per month in 2024, though higher-income beneficiaries pay more through income-related monthly adjustment amounts (IRMAA). At Mayo Clinic, Original Medicare coverage works through a fee-for-service model, meaning Medicare pays a portion of approved charges and the patient is responsible for deductibles, coinsurance, and any charges above Medicare's approved amounts.

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Part A coverage at Mayo Clinic includes inpatient hospital stays up to 60 days per benefit period with no coinsurance after the deductible is met. A benefit period begins the day you enter the hospital and ends 60 consecutive days after you leave. For stays between 61 and 90 days, coinsurance applies (coinsurance is when you pay a percentage of the cost). Skilled nursing facility care is covered after a qualifying hospital stay of at least three days, up to 100 days per benefit period, though coinsurance applies from day 21 onward. Part A also covers hospice care and some home health services following hospitalization or skilled nursing facility care.

Part B coverage at Mayo Clinic includes physician services, diagnostic tests, imaging, emergency room visits, outpatient surgeries, and preventive care. After meeting the annual Part B deductible (which was $240 in 2024), Medicare typically pays 80 percent of the approved amount for most services, and the patient pays 20 percent coinsurance. However, preventive services covered under Part B, such as annual wellness visits, cancer screenings, cardiovascular screenings, and bone density tests, are typically covered at 100 percent with no coinsurance after the deductible is met. Mayo Clinic bills Medicare directly for Part B services and balance bills are generally not allowed, meaning Mayo Clinic cannot charge the patient more than what Medicare approves.

Practical takeaway: Before a scheduled Mayo Clinic visit, ask the billing department whether your specific service is covered under Part B and what your estimated coinsurance will be. Request an estimate that breaks down the deductible amount you may still owe and the coinsurance percentage you will pay.

Medicare Advantage Plans and Mayo Clinic Network Status

Medicare Advantage, also called Part C, is an alternative to Original Medicare offered by private insurance companies like UnitedHealthcare, Humana, Aetna, Cigna, and Anthem. Approximately 28.5 million Medicare beneficiaries were enrolled in Medicare Advantage plans as of 2023, according to CMS. These plans bundle Part A, Part B, and usually Part D coverage into one plan sold by the private insurer. Many Medicare Advantage plans include additional benefits not covered by Original Medicare, such as dental, vision, hearing aids, fitness programs, or over-the-counter medication allowances. However, Medicare Advantage plans typically have network restrictions, meaning care received outside the plan's network may not be covered or may cost significantly more.

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Mayo Clinic's network status varies by region and by insurance company. In Minnesota, Mayo Clinic is generally in-network for most major Medicare Advantage plans, including UnitedHealthcare Medicare Advantage, Humana Medicare Advantage, and others. In Arizona and Florida, network participation may differ, and some plans may have limited or no in-network agreements with Mayo Clinic facilities in those states. The network status can also change annually when plans update their provider networks for the following year. A plan that included Mayo Clinic in 2023 might exclude it or add it in 2024, which is why annual verification is necessary.

When Mayo Clinic is in-network for a Medicare Advantage plan, patients typically pay lower out-of-pocket costs. Copayments or coinsurance may apply depending on the plan's design. For example, a primary care visit might have a $20 copay, while a specialist visit might have a $40 copay, and imaging might have a $200 copay. When Mayo Clinic is out-of-network, patients may be responsible for higher coinsurance (such as 40 percent instead of 20 percent), higher copayments, or the full charge if the plan does not cover out-of-network care at all. Some plans offer out-of-network benefits for emergency or urgent care but not for routine or elective services.

Practical takeaway: Call your Medicare Advantage insurance company before scheduling a non-emergency appointment at Mayo Clinic and ask specifically whether that Mayo Clinic location is in-network for your plan. Request written confirmation, as verbal confirmation alone may not protect you from unexpected bills if there is later a dispute about network status.

Understanding Costs: Deductibles, Copayments, and Coinsurance

Medicare beneficiaries receiving care at Mayo Clinic encounter three main types of out-of-pocket costs: deductibles, copayments, and coinsurance. Understanding the difference between these terms helps predict costs before arriving for care. A deductible is the amount a patient must pay before Medicare or the insurance plan begins to pay. Under Original Medicare Part B, the annual deductible was $240 in 2024. Under Medicare Advantage plans, deductibles vary widely but commonly range from $0 to $500 for in-network care, though some plans have higher deductibles. A copayment is a fixed dollar amount a patient pays at the time of service, such as $20 for a doctor's visit or $50 for an urgent care visit. Coinsurance is a percentage of the cost that the patient pays after the deductible is met, such as 20 percent of the approved charge.

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For Original Medicare at Mayo Clinic, after the Part B deductible of $240 is met in a calendar year, Medicare typically pays 80 percent of the approved amount for most services and the patient pays 20 percent coinsurance. However, the approved amount is not the same as what Mayo Clinic charges; it is the amount Medicare determines is reasonable for that service in that geographic area. Mayo Clinic must accept Medicare's approved amount as full payment and cannot bill the patient for the difference. For hospital stays under Part A, the deductible was $1,632 in 2024 for the first 60 days of each benefit period. After that deductible is met, there is no coinsurance for days 1-60, but coinsurance applies for days 61-90 ($408 per day in 2024) and for days