Does Medicare Cover Visits to See an ENT Doctor?

Medicare Benefits Solutions
Oct 11, 2022

Depending on your healthcare needs, you may find that your physician doesn’t have the expertise to help resolve your specific medical concerns. In many cases, your primary care provider may suggest you see a specialist, like an Ear, Nose and Throat doctor, AKA ENT.

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What is an Otolaryngologist?

An otolaryngologist is a physician qualified to diagnose and treat diseases of the head and neck. Structures involve the ears, throat, nose, oral cavity and face. This type of specialist is commonly known as an ear, nose and throat (ENT) doctor.

ENTs may offer care for a wide range of conditions from sinus congestion to throat cancer, and treatments can include outpatient respiratory therapy, prescription medications, and/or surgery for severe illness or injury.

If you have Medicare or will qualify soon, you’ll want to understand how visits to an ENT will be covered.

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Medicare ENT Doctors

If you have Original Medicare (Part A and Part B), you can use any healthcare provider across the United States who accepts Medicare. Be sure to confirm your doctor participates in the Medicare program and accepts assignment.

Medicare ENT doctors who accept assignment agree to bill Medicare directly, accept the amount Medicare approves, and charge you only the deductible and coinsurance.

TIP: Find out which Medicare plans offer the best benefits for hearing and other ENT services and compare them against your existing coverage.

Find Medicare ENT Doctors Near Me

If there is an ENT doctor near you that you want to see, you’ll need to confirm that they accept Medicare assignment before making an appointment. You can use an online plan finder tool to help you find a Medicare plan that includes ENT service providers.

Start your search by entering your zip code, what type of Medicare coverage you have and choose the main reason or reasons why you are thinking about changing your plan. Once you finish answering all the questions, including any specific doctors you want to see, you’ll get a list of recommendations that are unique to your specific needs.

When Would You Need to See an ENT?

Here are some of the conditions an ENT can diagnose and treat:

  • Ear diseases
  • Hearing loss, and hearing and balance disorders
  • Snoring, nosebleeds and sleep apnea
  • Hoarseness, cough and difficulty swallowing
  • Tumors anywhere in the head and neck
  • Gastrointestinal reflux (GERD)
  • Headaches and dizziness
  • Sinusitis

If you need to see a doctor about worries involving your head or neck, you may want to schedule a visit with an ENT, unless you are experiencing a problem with your eyes.

Ophthalmologists specialize in the function, structure and health of the eye. But if you experience worrisome headaches, hearing loss, snoring, allergies, or issues with swallowing, balance or speech, an ENT may be able to help.

If the ENT suspects the issue is related to your brain or nervous system, you may be referred to a neurologist.

Medications Prescribed by an ENT

If your ENT prescribes medications to treat your condition, you’ll need to have Medicare Part D prescription drug coverage to get help paying for them. If you have Original Medicare, you’ll want to enroll in a stand-alone Prescription Drug Plan.

Alternatively, you can enroll in a Medicare Advantage plan that includes your Part A, Part B, and Part D benefits. Each Part D plan will have its own formulary, or list of covered drugs, and costs can vary.

TIP: Discover what drugs are covered by the Part D plan.

Medicare Advantage Otolaryngologists Near Me

If you’re enrolled in a Medicare Advantage (Part C) plan, you may have to see doctors and specialists within your plan’s network. The type of plan you choose may determine whether you can see a specialist without a referral or see providers outside of your plan’s network.

Health Maintenance Organization (HMO) plans generally require the use of their provider networks except in emergencies. With a Preferred Provider Organization (PPO) plan, you may be eligible for out-of-network coverage, but out-of-network benefits are usually much less than in-network benefits.

For instance, an HMO may require you to see providers within the plan’s network or risk having to pay out of pocket for your doctor visits. A PPO, on the hand, may allow you to see a specialist, like an ENT, without a referral, or even visit an ENT outside of your plan’s network for a higher cost.

If you have Medicare Advantage, refer to the provider directory your plan has provided. It’s best to check your plan’s online directory rather than the printed version to get the most up-to-date information. Costs to see an ENT may include your Part B deductible and a copayment for office visits.

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

Medicare Coverage for Hearing and Oral Health

Original Medicare does not cover routine hearing exams, hearing aids, or visits for the fitting of hearing aids. However, if your doctor determines you need a hearing and balance exam to diagnose a medical condition and develop a treatment plan, Part B will cover 80% of the Medicare-approved amount after you satisfy the Part B deductible.

Medicare Advantage plans are required to include at least the same benefits as Original Medicare Part A and Part B. Many Medicare Advantage members enjoy extra benefits that extend beyond Original Medicare coverage. MA benefits vary from plan to plan, but may offer a range of perks, such as gym memberships and over-the-counter product allowances. You may have coverage for routine hearing exams, hearing aids and visits for fitting of hearing aids, vision care, and prescription drugs.

Medicare Advantage dental benefits generally include routine cleanings and X-rays. An annual maximum benefit may apply, and your share of the cost will vary with the plan. But routine oral health visits are important because dentists can detect diseases of the jaw bone and other health conditions. Your dentist may also be privy to local maxillofacial ENT doctors who accept Medicare.

TIP: Read more about Medicare coverage for hearing care, vision care and dental care services.

Best Ear Nose and Throat Doctors Near Me

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) is a large organization of specialists in otolaryngology, boasting roughly 13,000 members. Searching for an ENT through an organization like AAO-HNS is a good place to start.

ENTs specialize in a variety of medical conditions. Searching online lets you filter your search by choosing from different areas of expertise such as:

  • General otolaryngology
  • Broncho-esophagology (airway and swallowing issues)
  • Laryngology (voice box, vocal cords and swallowing)
  • Neurotology (hearing and balance)
  • Otolaryngic allergy (allergy and sinus disorders)
  • Otolaryngic pathology (diseases)
  • Otology (infections and hearing loss)
  • Pediatric otolaryngology (treatments for children)
  • Rhinology (nose and sinuses)
  • Sleep medicine (snoring or sleep apnea)

ENT surgery specialties:

  • Maxillofacial (disease, injury, or deformity of the face, jaw, or mouth)
  • Endocrine (thyroid/parathyroid)
  • Facial plastic and reconstructive (cosmetic)
  • Head and neck (tumors of the head or neck)
  • Skull base (growths on the underside of the brain)

TIP: Use a Medicare plan finder and discover if your existing plan covers ENT or other specialty services.

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