Medicare has a range of plans for healthcare coverage that many doctors, clinics, and hospitals accept. When an individual is researching Medicare plans, they should consider which doctors or healthcare facilities nearby accept Medicare.
There are several online tools, such as Physician Compare, that can help you locate a Medicare-approved doctor nearby.
Choosing the best Medicare plan for a specific location will grant a person access to a network of doctors and hospitals that accept Medicare payments. Selecting a suitable plan may also help a person reduce out-of-pocket expenses.
It is each person’s responsibility to verify that their particular Medicare plan covers specific healthcare services. The person must confirm coverage before any treatment, as the hospital does not confirm coverage on their behalf.
In this article, we explain how to check which doctors near you accept Medicare.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
There are several ways to find a doctor who accepts an individual’s Medicare plan.
The Physician Compare tool
The Centers for Medicare and Medicaid Services (CMS) provide a simple tool called Physician Compare.
A person can enter their zip code, and the tool will display a list of doctors and healthcare facilities in the area that accept Medicare plans.
People can also search by a healthcare professional’s last name, the practice name, or the medical specialty they require.
To filter the search, a person can select:
- how far from their location they want to search
- the gender of clinician they feel most comfortable visiting
- whether they are part of a group or running a solo practice
- their board certification status
The doctors listed on Physician Compare accept Medicare, but the tool does not provide information about secondary insurance, such as Medicaid.
An individual will need to contact their secondary insurance provider to make sure their preferred doctor accepts the terms of their plan.
Read more on Medicare’s coverage for doctor visits.
The Medicare website
The official Medicare website provides resources and tools for finding local doctors and healthcare services that accept Medicare.
These services include:
- dialysis facilities
- home health services
- long-term care hospitals
- inpatient rehabilitation facilities
Medicare provides a Service Coverage tool that an individual can use to find out whether their Medicare plan covers a test, item, or service
The Find and Compare Doctors, Hospitals, and Other Providers tool allows an individual to search for providers based on their current health needs and Medicare plan.
Insurance company provider information
Private insurance companies provide some Medicare plans, including Medigap and Medicare Advantage.
If an individual has a privately administered Medicare service, they should ask their insurance provider about local doctors who accept payments from this coverage.
Usually, insurance companies have a limited network of doctors, hospitals, and healthcare services that accept their payments.
Find your insurance company’s customer service phone number or website in your enrollment documents or search for them online.
Ask other people
An individual could ask neighbors and other people who live in their area and who have Medicare about the healthcare services they use. Internet forums and other websites can also provide relevant information.
An individual is free to accept services from any healthcare professional. However, a doctor who does not accept Medicare may have higher rates.
If a person does not verify their Medicare coverage for a particular healthcare service, they may be responsible for the full amount.
Doctors who accept Medicare will charge a specially negotiated rate. Doctors must opt-in for Medicare and agree to accept their plans as payment for services.
Opting-in to Medicare means that they agree to the service terms that the Federal government sets.
Learn how Medicare reimburses healthcare costs to healthcare providers.
If an individual has Original Medicare, they are free to visit any doctor or healthcare professional who accepts Medicare payments and provides eligible treatment.
The rules for Medicare Advantage are different and depend on the terms of a particular plan. Some Advantage plans require that an individual uses doctors in the provider network, unless in an emergency. These include:
- Health Maintenance Organization (HMO): These plans often have lower costs than other Advantage plans because an individual must use service providers within the plan’s network. A primary care doctor will coordinate all care and referrals.
- HMO Point of Service (HMPOS): These plans typically have provider networks. Visits to out-of-network service providers will cost more.
- Preferred Provider Organization (PPO): PPO plans usually cost less if a person uses in-network service providers. Doctors outside the plan’s network could incur higher out-of-pocket expenses. An individual with a PPO need not choose a primary care physician.
- Special Needs Plan (SNP): Medicare designs SNP plans for people with specific health conditions. An individual must choose healthcare providers in the SNP network, except for emergency care, or if an individual has end stage renal disease (ESRD) and needs out-of-area dialysis.
With Original Medicare, an individual is free to choose any Medicare-enrolled doctor, healthcare provider, clinic, or hospital. An individual need not select a PCP and can visit different doctors if they prefer.
Some Medicare Advantage plans require that an individual chooses a PCP from the network of providers. An individual can change their PCP whenever they want to by contacting the insurance provider.
Most insurance companies have an online portal for selecting a new PCP, and they provide a list of approved local doctors who accept someone’s particular Medicare Advantage plan.
Insurance companies can change their healthcare provider network as they choose and at any time.
If an insured person’s primary care doctor leaves the provider network, and the individual does not wish to change doctors, they have several options:
Change between Medicare Advantage plans
If an individual finds that their PCP is part of another Medicare Advantage plan’s provider network, they can change to this plan during the annual enrollment period (AEP).
According to Medicare.gov, this period begins on October 15 and ends December 7. Any changes a person makes to their plan during this enrollment period will come into effect in January of the following year.
Leave the plan
A doctor may leave all Medicare Advantage networks but continue to accept Medicare. In this case, an individual can change to Original Medicare and receive coverage to see the particular doctor.
An individual with a Medicare Advantage Plan can make this change during the AEP or during the second open enrollment period from January 1 to March 31.
Change plans during a Special Enrollment Period
Changes to the provider network may trigger a Special Enrollment Period (SEP). This may occur due to changes in the contract between the Centers for Medicare and Medicaid Services (CMS) and the plan provider.
Alternatively, they may not renew the contract or may reduce the size of its service area.
If this happens, the plan provider will contact the individual. They can then enroll in a different Medicare Advantage plan or Original Medicare.
An individual may also experience changes in their life that affect their insurance circumstances. They may also qualify for a SEP.
Qualifying life events include:
- changing immigration status
- having or adopting a child
- losing employer-provided health insurance
- marrying or divorcing
- moving to a new location with a different insurance coverage area
For most people, having a local and convenient doctor they trust is an important part of healthcare.
It is worth taking the extra step to verify that your doctor accepts Medicare coverage. This can help an individual make sure they get the most from their Medicare benefits and keep out-of-pocket expenses to a minimum.