If you have a favorite medical specialist and you qualify for Medicare, can you keep that specialist? Some health plans restrict you to doctors and specialists in the plan’s network. But you still might be able to keep your specialist when you’re enrolled in Medicare – read on for details.
Specialists and Original Medicare
If you’re enrolled in Original Medicare (Part A and Part B), Medicare may cover visits to your specialist if she or he accepts Medicare assignment. That’s an agreement that the doctor will accept the Medicare-approved amount as full payment for covered services. You might have to pay a deductible and/or coinsurance or copayment amount, just as you would with most Medicare covered service.
Specialists and Medicare Supplement insurance
You might be able to buy a Medicare Supplement insurance plan to work alongside your Original Medicare coverage. Medicare Supplement (Medigap) plans are available from private health insurance companies. They’re designed to help cover your Medicare Part A and Part B out-of-pocket expenses, such as coinsurance, copayments, and deductibles.
Most Medicare Supplement plans don’t have provider networks, so you can visit any specialist that accepts Medicare assignment. There’s one type of Medicare Supplement plan, called a Medicare SELECT plan, that may require you to use doctors and specialist in the plan’s network. Even if you have a Medicare SELECT plan, it’s possible that your specialist is in the plan’s network; just call the plan or the doctor’s office and ask.
Specialists and Medicare Advantage plans
There are several types of Medicare Advantage plans. You may have to visit specialists within the plan’s network, depending on the type of plan you sign up for. Some Medicare Advantage plans may cover specialist visits outside the plan network, but charge higher coinsurance or copayments for these services.
Also, be aware that some Medicare Advantage plans let you arrange to see a specialist without a referral from your primary care provider (PCP), but other plans require you to get a referral.
How can I find out if my specialist is in a Medicare health plan’s network?
If you’re looking at Medicare health plans that have provider networks – such as some Medicare Advantage plans – here are a few ways you can find out if your specialist is in a certain plan’s network.
- Call the plan’s customer service number, or see if the plan’s website lists network doctors (they often do).
- Call your specialist’s office and ask if he’s in the plan’s provider network.
- When you find a doctor you’re interested in, call the doctor’s office to find out if s/he is in the plan’s network.
Would you like some help understanding Medicare health plan networks and their rules about specialists, I’d be happy to explain them to you.
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Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.
The provider network may change at any time. You will receive notice when necessary.
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