Does Medicare Cover a Second Opinion?

Medicare does not cover a second opinion for elective surgeries and non-Medicare covered services such as cosmetic surgery. However, if your doctor or primary care provider has recommended a medically necessary surgical procedure then Medicare will cover getting a second opinion.

A second opinion can help you make an important decision about your available treatment options. Medicare will also cover a second opinion if your physician has recommended a major therapeutic or diagnostic procedure.

Why Should I Get a Second Opinion?

If your physician has just told you that you need surgery, you might feel a bit overwhelmed. But if your surgery isn’t an emergency, you should take the time to get a second opinion from another doctor before deciding to go ahead with the procedure. 

If you need emergency surgery for a condition such as appendicitis, blood clot, aneurysm, or severe injury, you shouldn’t delay the procedure waiting for a second opinion. But if your physician proposes having surgery to treat or diagnose a non-emergency condition, you should consider asking for a second opinion. In cases like these, Medicare can help you cover your expenses.

TIP: Sign up for the Medicare Benefits newsletter to get more of your emergency services and surgical-related questions answered.

Getting a Second Opinion Before Surgery

Getting a second, or even third opinion from other healthcare providers makes sense for several reasons:

• First of all, you can get more information about your diagnosis and treatment options. This helps add safeguards against possible misdiagnosis or mistreatment. Statistics show that in the United States every year, there are around 12 million people who are misdiagnosed, and 50 percent of them are at risk for potentially serious harm due to a misdiagnosis.
• Making a diagnosis is a complicated process in many cases, and an initial diagnosis isn’t always a conclusive one. It might be a cliché, but “two heads are better than one” isn’t a bad thing to have when it comes to your health. 
• Your condition might have more than one treatment option. For example, breast cancer can be treated by mastectomy or lumpectomy; or chronic back pain may respond to physical therapy before turning to surgery. In some cases, getting a second opinion might help a person find a treatment that is more successful for their condition.

TIP: Find out which Medicare plans offer additional benefits and compare them against your existing coverage.

Does Original Medicare Cover a Second Opinion?

Original Medicare Part B (medical insurance) covers a second opinion for non-emergency surgeries or medical procedures that have been certified as medically necessary. To be eligible for this benefit, all doctors or other health care providers involved must accept Medicare assignment. If you get a second opinion that is different from your initial physician’s opinion, Medicare Part B helps pay for a third opinion if you wish to get one. 

If the second healthcare provider you visit prescribes further tests, Medicare Part B also covers its share of these tests as well as the medical services. In the instance where your first and second opinions differ, Medicare pays its share of a third opinion. Medicare pays 80 percent of the final approved costs for medical services and tests related to a second and third opinion. You pay the remaining 20 percent and your Part B deductible for the current year. 

Does Medicare Advantage Cover a Second Opinion?

Your Medicare Advantage (Medicare Part C) plan is required to cover a second opinion when it is for a medically necessary procedure. Also, if the first and second opinions differ, your plan must help pay for a third opinion. 

While Medicare Advantage plans must provide the same coverage that Original Medicare Parts A and B do, providers have the right to require that beneficiaries use doctors and other health care providers that are in the plan provider’s network of providers. Also, depending on the plan you have, you might only have coverage for a second opinion if you get a referral from your primary care physician. 

To ensure that you have the coverage you need for a second or third opinion, check your plan’s policy or call a plan representative for assistance.

TIP: Discover the top 7 reasons to switch your Medicare Advantage plan.

MULTIPLAN_HCIMB37SDO_2022