Are you a Medicare beneficiary who is looking for a primary care physician? Will your primary care physician accept your Medicare Advantage plan, if you are enrolled in one? This guide can help you as you compare your local health care options and your Medicare coverage.
For certain types of Medicare Advantage (Medicare Part C) plans, you may need to select a primary care physician.
In some instances, you’ll need to find a primary care physician who participates in your plan’s network and will accept your Medicare Advantage plan coverage.
If you have Medicare Part A and Part B, you'll need to find out if a primary care physician accepts Medicare patients and accepts Medicare assignment (more information on that, below).
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No matter what type of Medicare plan coverage you have, you will want to access health care providers who are enrolled in Medicare. This can help make sure you receive covered care.
If you wish to find out if any Medicare Advantage plans are available in your area and what primary care physicians are available, you can speak with a licensed insurance agent at 1-800-557-60591-800-557-6059TTY Users: 71124 hours a day, 7 days a week.
How do I find a doctor who accepts Medicare assignment?
There are three different types or levels of Medicare participation that health care providers can be designated.
Accepts Medicare assignment This means the doctor accepts Medicare patients and agrees to accept the Medicare-approved amount as full payment for their goods or services.
Does not accept assignment This means the doctor accepts Medicare patients but does not accept the Medicare-approved amount as full payment.
Non-participating Doctors in this category do not accept new Medicare patients.
So how do you make sure the provider you visit will accept your Medicare insurance as payment?
If you are enrolled in Original Medicare (Part A and Part B), you can use the Physician Compare tool from Medicare.gov, the official Medicare website.
For Medicare Advantage or Medicare Part D plans, you can contact your plan directly for a list of participating providers.
Medicare Supplement Insurance plans are accepted anywhere that Original Medicare is accepted.
Will my doctor accept my Medicare Advantage plan?
Have you enrolled in a Medicare Advantage plan and need to choose a primary care physician for the first time? Are you looking to switch from one primary care physician to another while remaining in your current Medicare Advantage plan?
In any case, you can contact your Medicare Advantage plan provider directly, and a representative should be able to provide you with a list of primary care physicians in your area who participate in your Medicare plan.
Many Medicare Advantage plan providers may offer a doctor search tool on their website as a way for you to find a participating primary care physician in your area.
Some Medicare Advantage plans allow members to switch primary care doctors at any time, though you should check in with your plan specifically to find out for sure.
Not every type of Medicare Advantage plan requires a primary care doctor.
A Medicare HMO (Health Maintenance Organization) plan generally requires the use of a primary care doctor, and you must obtain referrals before seeing a specialist. You typically cannot receive out-of-network care that will be covered by your HMO, except for emergency situations or when out-of-network kidney dialysis is required.
Medicare PPO (Preferred Provider Organization) and Medicare PFFS (Private-Fee-For-Service) plans do not require a referral from a primary care doctor in order to see a specialist. Members are also not typically required to select a primary care physician, though you still have the option of using a primary care doctor in order to coordinate your care.
For Original Medicare (Part A and Part B), you do not need to utilize a primary care doctor. Any doctor who accepts Medicare and is enrolled in the federal Medicare program should be able to provide you with covered health care services.
How do I find a Medicare plan that accepts my primary care physician?
A licensed agent can help you review Medicare Advantage plans available in your area and may be able to provide you with information about primary care physicians located near you who participate in each given plan.
A licensed insurance agent can also help you find out which specialists, pharmacies, laboratories and other health care facilities in your area participate in the plan, along with all the cost details associated with each plan.
What to look for in a primary care physician
Your primary care doctor can serve as the cornerstone of your health care services, so it’s important to find a doctor who accepts your Medicare coverage.
The tips below may help you during your search.
Find out which primary care doctors are “in-network” If you receive all of your health care from doctors that are part of your plan’s network, you will typically pay less in out-of-pocket costs than if you received care from physicians outside of your plan network.
Depending on which type of Medicare Advantage plan you belong to, you may receive less coverage when receiving care outside of the network, or you may pay entirely out of pocket.
Decide which type of doctor you’d like to have There are several different types of doctors who can all serve as a primary care physician. Just a few examples of doctors who may be used by a senior on Medicare can include:
A family practice doctor generally has a wide range of skills and can sometimes treat injuries or ailments that might otherwise require a specialist.
A doctor with “D.O.” (Doctor of Osteopathic Medicine) after their name – instead of the traditional “M.D.” (Doctor of Medicine) – may combine some traditional medical training with additional and alternative medicine practices. This will depend on the particular doctor.
An internal medicine doctor, or internist, specializes in the prevention, diagnosis and treatment of diseases in adults.
Ask your friends and family It never hurts to ask your close friends and family about their doctor. What has been their overall experience with their doctor? What do they like and do not like about them? Does this physician sound like someone you might want as your doctor?
Learn more about the specialists you may need to visit Your primary care doctor may refer you to specialists within the plan’s network when needed (some types of plans require members to get a referral from their primary care physician before seeking specialized care).
If you have a particular condition that may warrant regular trips to a specialist, you may want to consider not only the primary care doctor you will select, but also the specialists who you will likely visit for additional care.
Visit the doctor If you are enrolled in Original Medicare, you may consider scheduling a checkup with a doctor near you utilizing one of Medicare’s covered preventive services, such as your one-time “Welcome to Medicare” visit or your yearly wellness visit.
You can use the opportunity to meet the doctor and check out the facility. You can also evaluate how easily you were able to schedule an appointment, how friendly the staff was and evaluate other environmental factors that might influence your choice when selecting a primary care physician.
Benefits of using a primary care physician
Although not every type of Medicare plan requires the use of a primary care physician, there are plenty of reasons why some beneficiaries may find it useful to select a primary care doctor.
Continuity When you visit the same doctor for all of your ailments, that doctor can often get to know you and your health, and they can have direct insight into your health history.
Coordinated care One part of the role of a primary care physician is to coordinate a patient’s care between various specialists, labs and other health care facilities. This type of coordinated care can help improve communication and foster a more “team” approach to your care.
Convenience With a primary care physician, you can receive a wide range of treatments all in one place. No matter what ails you, you know exactly where to start for receiving care.
Early detection Regular visits to the same doctor can help increase the chances of early detection of health issues, especially when annual checkups and preventive screenings are utilized.
Increased trust Seeing the same doctor all the time can help foster a trusted patient-physician relationship, which can improve communication and make it easier to have discussions about your body and health.
Get additional help finding a primary care physician who accepts your Medicare plan
Contact a licensed insurance agent for additional help finding a primary care physician near you who accepts your Medicare plan. Find out more about the Medicare Advantage coverage options in your area by calling a licensed insurance agent at1-800-557-60591-800-557-6059TTY Users: 711 24 hours a day, 7 days a week, or by requesting a free no-obligation quote on line.
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.
Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.
Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.
If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.
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