Does Medicare Cover Second Opinions?

Medicare typically does cover second opinions when your doctor recommends you for non-emergency surgery that is medically necessary.

Medicare Advantage (Part C) plans may also cover second opinions, and they also include an annual out-of-pocket spending limit. This can potentially save you money in Medicare costs for your surgery and other medical costs.

Original Medicare does not include an out-of-pocket spending limit.

A woman gets a second opinion from a doctor and nurse

When does Medicare cover a second opinion?

A second opinion can be useful when your doctor gives you recommendations on an injury, surgery or illness that you would like another opinion on from another doctor.

Medicare Part B (medical insurance) will cover a second opinion when your doctor recommends you for surgery that to diagnose or treat an injury or health issue that isn’t an emergency.

If you are suffering from an emergency that requires surgery, such as appendicitis or a blood clot, your surgery should be performed without waiting for a second opinion, if ordered by your doctor.

Medicare Part B does not cover second opinions for elective or cosmetic surgery. Medicare may even approve a third opinion if the first two are different from one another.

If your second doctor gives you an opinion that is different from your first doctor, you may consider getting a third opinion from a third doctor. Medicare Part B covers a third opinion if the first and second opinions are different.

Do Medicare Advantage plans cover second opinions?

If you have a Medicare Advantage plan, your plan may have a network of providers that you are required to see. Your plan may also require you to get a referral from your primary care physician (PCP)  before getting a second opinion.

Be sure to speak directly with your plan carrier for more information on how your plan may cover second opinions.

How much does a second opinion cost with Medicare?

If Medicare Part B covers your second opinion, you may face of out-of-pocket costs that include:

  • Part B deductible
    You must pay the Part B deductible before your coverage kicks in for the year. In 2019, the Part B deductible is $185 per year.

  • Part B coinsurance
    After you meet your Part B deductible, you are typically responsible for paying a 20 percent Part B coinsurance of the Medicare-approved amount for your doctor’s services.

If you have a Medicare Advantage plan, you should check with your plan carrier for more information on your costs for getting a second opinion.

Medicare Advantage plans include out-of-pocket limits and other benefits

Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare. Every Medicare Advantage plan must cover everything that Part A and Part B cover, and all Medicare Advantage plans include a yearly out-of-pocket spending limit.

Many Medicare Advantage plans may include prescription drug coverage, and some Medicare Advantage plans may also offer additional benefits, such as:

To learn more about Medicare Advantage plans in your area and if you’re eligible to enroll, call to speak with a licensed insurance agent. They can help you compare plans and find one that fits your budget and your coverage needs.

 

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