48% of Medicare Beneficiaries Skipped or Delayed Care Because They Didn’t Understand Their Coverage. Another 54% Worried About Out-of-Pocket Costs

Picture a 72-year-old retiree whose cardiology referral has been sitting on her kitchen counter for six weeks. She can’t tell whether Medicare covers the visit or how much she would owe, so she hasn’t called. Plenty of people are in the same spot.

An eHealth (NASDAQ:EHTH) survey of more than 1,000 Medicare beneficiaries, published October 8, 2026, found that 48% had skipped or delayed medical care in the past year because their coverage confused them. 54% had skipped or delayed care or a prescription because they worried about out-of-pocket costs.

Many beneficiaries misunderstand the basics. In eHealth’s August survey, 42% of current beneficiaries didn’t know or underestimated the 20% coinsurance Original Medicare typically charges. Another 88% either didn’t know or wrongly thought that Original Medicare caps annual out-of-pocket costs. It has no cap. If you carry a Medigap Plan G, your specialist costs mostly come down to the annual Part B deductible. The math below matters most if you have Original Medicare with no supplement, or a Medicare Advantage plan that requires referrals.

An Appointment She Never Scheduled

Three unknowns usually stall the call. Does the specialist take her coverage? Does she need a referral or prior authorization? What will her share be? A phone call to her doctor’s office or Medicare plan can help clear things up.

Confusion and denial lead to very different places. A denial is a written decision from Medicare or the plan, and it comes with appeal rights. Confusion leaves no paperwork and no way to appeal. It just leaves a heart problem that nobody has checked.

What Medicare Will Pay

Original Medicare lets her see any specialist who accepts Medicare, with no referral and no network. She covers the Part B deductible, $283 in 2026, up from $257 in 2025, and then 20% of the Medicare-approved amount. Doctors who accept assignment, which means they are satisfied with the program’s payment for a service, can charge her only the Medicare deductible and coinsurance amount. Non-participating doctors can charge more, but in many cases no more than 15% above the Medicare-approved amount. Doctors who opt out of Medicare are the real risk, because Medicare won’t pay for items or services they provide except in emergencies.

Medicare Advantage sets its own specialist copays. Many HMO plans require a referral from a primary care doctor, and plans can require prior authorization for certain services. If she visits an out-of-network specialist in an HMO without approval, she may owe the entire bill, except in situations where the plan must cover out-of-network care. So the check call matters more for Advantage enrollees than anyone else.

A Denied Claim Versus a Feared Bill

Consider a hypothetical $400 Medicare-approved cardiology visit with a doctor who accepts assignment. She has Original Medicare without a supplement.

She’s afraid of a $400 bill, or worse. With a doctor who accepts assignment, the most she pays is $306.40, and the deductible she pays at that visit covers her for the rest of the year. That cost is real money. The average retired worker’s benefit is an estimated $2,095 a month before the 3.6% 2027 cost-of-living adjustment (COLA), and the 2026 Part B premium already takes $202.90 of it, before any IRMAA surcharge linked to income from two years ago (one of several Medicare traps we mapped in a free guide here). Still, a known $80 bill is far easier to plan around than a bill she only guesses.

How to Find Out Before Postponing Treatment

1. Call the specialist’s billing office first. If you have Original Medicare, ask: “Do you accept Medicare assignment?” If you have Advantage, ask: “Are you in network for my plan in 2026 and 2027?” Ask for the billing codes and a written estimate. For outpatient procedures, Medicare.gov’s Procedure Price Lookup tool shows costs based on Medicare’s 2026 payments and copayments.
2. Advantage enrollees: ask for a coverage decision in writing before the visit. Call the member services number on your card, confirm whether you need a referral or prior authorization, and ask for a pre-service determination. If the plan says no, you can appeal before you owe anything.
3. Re-check your plan’s network before the Annual Enrollment Period ends December 7. If your specialist leaves your Advantage plan’s network for 2027, look for a plan that still includes that doctor before the new plan year begins January 1.

Medicare covers specialist visits. Original Medicare’s cost is a fixed formula, and Advantage plans publish their copays and referral rules. When you aren’t sure about coverage, make a phone call before you put off care you need.

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