Choosing your own doctor

By Medicare Benefits - May 4, 2020

The doctor-patient relationship is important. If you’ve built a rapport with a specific physician over time or are in the midst of treatment for a chronic illness, the idea of changing doctors could be stressful. Getting Medicare insurance for the first time may mean having to switch doctors, but you may have more options than you think.

When you are eligible for Medicare, you’ll have some choices to make. You can enroll in Original Medicare or Medicare Advantage to get your Part A (hospital insurance) and Part B (medical insurance) benefits. How will your decision affect the doctors you can visit? It depends on the plan you choose.

What doctors can I see with Original Medicare? 

When you have Original Medicare, you can visit any physician, hospital, provider, or supplier who “accepts assignment.” If a provider accepts assignment, they agree to accept Medicare’s approved amount as full payment for treatment, supplies, or equipment. Doctors who don’t accept assignment can charge more for your care, and you will be responsible for any additional charges. 

According to the Kaiser Family Foundation, more than 90% of primary care physicians in the United States accept Medicare. If you are new to Medicare, call a doctor’s office before visiting for the first time to make sure they are accepting new patients. 

If you purchase a Medicare Supplement, or Medigap, policy, it may help pay for coinsurance, copayments, deductibles and more - and you can visit any physician or medical provider who accepts Medicare. 

What doctors can I see with a Medicare Advantage plan?

If you enroll in Medicare Advantage, your choice of doctors will depend on the plan you choose. MA plans are offered by private insurance companies that contract with Medicare to provide your Part A and Part B benefits, but costs, coverage, and the network of providers vary between plans. MA plans work with networks of doctors, hospitals, suppliers, and pharmacies, but some types of plans are more flexible than others. 

Let’s review some of the most common types of Medicare Advantage plans to find out how they manage their network of providers: 

Health Maintenance Organization (HMO)

If you enroll in an HMO, you’ll likely have to choose a primary care physician who will coordinate your care. You’ll need to see your primary care physician to get a referral to see a specialist. If you visit a physician without a referral or outside of the plan’s network, you may have to pay the full cost of services. 

Preferred Provider Organization (PPO)

PPOs generally give you a bit more flexibility than HMOs. When you enroll in a PPO, you will still pay less if you visit doctors, health providers, and hospitals within the plan’s network, but you can go outside the network and pay more for your services. You do not need to choose a primary care physician, and you can see a specialist without a referral. If you go outside the plan’s network to see a specialist, you will likely pay more. 

Private Fee-for-Service (PFFS) Plans

Some PFFS plans will allow you to visit any provider who accepts Medicare, while others will require you to visit doctors, hospitals, and suppliers within the plan’s network. 

Special Needs Plans

If you qualify for a Special Needs Plan because of a chronic condition or specific circumstance, you will likely have to choose a primary care physician or care coordinator within the plan’s network. You will generally have to get a referral to see a specialist within the network. If you visit a doctor outside of the network, you may be responsible for the full cost of your care.

Comparing plans

If you are concerned that you won’t be able to keep seeing your doctor after you sign up for Medicare, you can call your doctor’s office to find out if they accept assignment.  If you are considering Medicare Advantage plans, find out if the plans you’re considering will allow you to continue seeing your primary care doctor or specialist.

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“I’m Mary-Beth*. I can carefully walk you through our step-by-step process to help you find a plan that meets your needs.”

Find a plan* Mary-Beth is a digital avatar and not a licensed sales agent.

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