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Will My Specialist’s Services be Covered under My Medicare Plan?

Whether you’re switching from one type of Medicare coverage to another, or you’re new to Medicare, you might be concerned about being able to continue seeing your health-care specialist.

Will your specialist’s services be covered by Medicare? That may depend upon:

  • Whether your specialist accepts Medicare assignment (she or he agrees to accept the Medicare-approved amount for a service as the entire payment, and won’t bill you above the appropriate deductible and/or cost-sharing amount)
  • Whether your specialist is part of your Medicare health plan’s provider network, if this applies to you.

As a Medicare beneficiary, you may have options to how you receive your Medicare coverage.

Medicare specialists and Original Medicare, Part A and Part B

Here’s what to expect when you see a specialist when you have Original Medicare coverage. Original Medicare is the health insurance program administered by the federal government and consists of two parts: Part A provides hospital insurance and Part B generally provides medical insurance, such as doctor visits.

In order to receive the most from your Medicare Part B coverage (and minimize your out-of-pocket expenses for health-care services), you may want to make sure you go to Medicare specialists when you need specialized care. That is, make sure the specialist accepts Medicare assignment. You can call and confirm this with your specialist.

Generally Medicare doesn’t pay for care you receive from doctors who “opt out” of Medicare. The term “opt out” generally refers to a formal process by which a doctor communicates his or her decision not to accept Medicare payments.  Doctors who do not accept Medicare do not submit medical claims to Medicare on behalf of their patients and they are not subject to the Medicare law that limits the amount they may charge patients with Medicare.

How can you find out if you have a Medicare-assigned specialist?

To make sure you have Medicare coverage for a specialist for Medicare-covered services:

  1. Call your doctor and ask whether he or she accepts Medicare assignment. You can also verify your specialist’s status with Medicare at Medicare.gov. Simply enter your zip code and you can perform a search by your doctor’s name, specialty, or clinic name.
  2. If your specialist doesn’t accept Medicare assignment, you might have several choices:
  • Change to a specialist who accepts Medicare assignment.
  • Continue to receive care from your specialist and risk paying more than the Medicare-approved amount for services – in some cases, you might pay the full cost of care out-of-pocket.
  • Check to see if a Medicare Supplement (Medigap) plan is available that may pay a portion of the costs for the specialist’s Medicare-covered services. Medicare Supplement plans are offered by private insurance companies and can help you pay out-of-pocket costs for services covered under Medicare Part A and Part B. In most states, up to 10 standardized Medicare Supplement plans may be available.  Medicare Supplement Plans F and G might provide coverage for “excess charges” under Medicare Part B for doctors who don’t accept Medicare assignment.

Specialists and Medicare Advantage plans

Medicare Advantage plans are offered by private insurance companies that contract with the government to provide Medicare coverage.  With the exception of hospice care, which remains a Medicare Part A covered service, Medicare Advantage plans must offer at least the same level of Medicare coverage as Part A and Part B. However, some Medicare Advantage plans offer more benefits than Original Medicare, Part A and Part B.  Many Medicare Advantage plans have networks of hospitals, Medicare specialists, and other health-care providers.

Coverage for your specialist’s services may depend upon the type of Medicare Advantage plan you choose for your Medicare coverage.

  • Medicare Advantage Health Maintenance Organizations (HMO): If you enroll in a Medicare Advantage HMO, you usually have to use the plan’s provider network for non-emergency health services in order to receive benefits for covered services.  Unless you have the plan’s approval, your Medicare specialist must be part of the Medicare Advantage HMO network for the plan to pay for covered services.  Because a Medicare Advantage HMO is structured around the concept of care coordination, you will likely need a referral from your primary care physician (PCP) before you see your specialist. Check with your Medicare Advantage plan for more information.
  • Medicare Advantage Special Needs Plans (SNP): If you enroll in a Medicare Advantage Special Needs plan, you usually must use the plan’s provider network for non-emergency services in order to receive benefits for covered services. You will need your primary care physician’s referral to your specialist in most cases.
  • Medicare Advantage Preferred Provider Organization (PPO)*: Your Medicare specialist’s services for Medicare-approved services may be covered regardless of your doctor’s status with the plan’s network. However, your costs will usually be lower if your specialist is in the Medicare Advantage plan’s network.  Typically you don’t need a referral to a specialist.
  • Private Fee-for-Service (PFFS) Plans: With this type of Medicare coverage, your Medicare specialist’s services may be covered by the PFFS plan if your doctor agrees to accept the plan’s coverage and fee schedule. While you don’t need a referral to see your specialist, it is a good idea to check with your specialist at each visit to verify if your doctor will accept the PFFS plan, because health-care providers can usually decide whether or not to accept the plan and its fee schedule on a case-by-case basis.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

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