When researching Medicare plans, individuals can consider which doctors or healthcare facilities nearby accept Medicare. Several online tools can help locate a Medicare-approved doctor.
Medicare has a range of plans for healthcare coverage that many doctors, clinics, and hospitals accept.
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.
This article explains how to check which doctors near you accept Medicare.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance 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.
Medicare
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 check whether their Medicare plan covers a test, item, or service.
The Physician Compare tool
The Centers for Medicare and Medicaid Services (CMS) provides 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 areas 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 sex of the 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.
Learn more about Medicare coverage for doctor visits.
Insurance company provider information
Private insurance companies provide some Medicare plans, including Medigap and Medicare Advantage (Part C).
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 can 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 set by the Federal government.
If an individual has Original Medicare, they can 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 Medicare Advantage plans require that an individual uses doctors in the provider network, unless in an emergency. These plans include:
- Health Maintenance Organization (HMO): HMO 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): HMPOS plans typically have provider networks. Visits to out-of-network service providers will usually 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 and needs out-of-area dialysis.
Learn more about the difference between HMO and PPO plans.
With Original Medicare, an individual can choose any Medicare-enrolled doctor, healthcare professional, clinic, or hospital.
Some Medicare Advantage plans require that an individual chooses a primary care physician (PCP) from the network of providers. An individual can change their PCP whenever they want 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 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 open enrollment period, which is from October 15 to December 7
- the Medicare Advantage open enrollment period, which is between January 1 and March 31
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 that particular doctor.
An individual with a Medicare Advantage Plan can make this change during the open enrollment period or Medicare Advantage open enrollment period.
Change plans during the special enrollment period
The special enrollment period allows individuals to switch to another plan due to certain circumstances, such as:
- moving to a new address outside the current plan’s service area
- getting married
- having or adopting a child
- losing employer-provided health insurance
A person typically has 60 days before or after the event to enroll in the new plan.
Changes to the provider network may trigger the special enrollment period. This may occur due to changes in the contract between the 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.
Find out about the different enrollment periods.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
There are various sources that can help a person find a doctor near them who accepts Medicare. These include the Medicare website, the Physician Compare tool, and insurance company provider information.
Not every doctor accepts Medicare. It is up to the individual to check that the doctor accepts Medicare, or they may need to pay costs in full.
It is worth taking the extra step to verify that a doctor accepts Medicare coverage. This can help ensure a person gets the most from their Medicare benefits and keep out-of-pocket expenses to a minimum.