Medicare Coverage of Primary Care Physicians
If you have Original Medicare (Medicare Part A and B), then you don’t need to choose a primary care physician. In general, you can see any health care provider, but your costs are lower if you get care from a Medicare-approved primary care physician who is accepting new patients. However, some types of Medicare Advantage plans require you to see a primary care doctor before you see a specialist.
What is a primary care physician?
For certain types of health plans, such as Health Maintenance Organizations (HMOs), your primary care physician is the doctor you usually first see about a health problem. He or she helps you get the right care and may talk with medical specialists about your case and refer you to them. Usually, you’ll receive primary care in an outpatient setting, like a doctor’s office or clinic. Often, a primary care physician will be involved in your medical care for a long time, and having a primary doctor may give you a trusting, ongoing relationship with one medical practitioner for a while.
Usually, a primary care physician’s role is to:
- Offer preventive care and advice on living a healthy lifestyle.
- Treat common medical conditions.
- See what medical problems are urgent and direct you to the right place for care.
- Make referrals to medical specialists when needed.
Types of primary care physicians
In the past, people relied on doctors for the health care of their entire family. Modern-day primary care physicians have brought this tradition back by helping patients maintain their overall health. There are different types of primary care doctors:
- Family practitioners who treat children and adults of all ages
- Internists who treat adults of all ages for many different medical problems
- Geriatricians who treat people with medical needs due to aging
- Obstetricians/gynecologists who often serve as a primary care physician for women, especially those of childbearing age
- Pediatricians who treat newborns, infants, children, and adolescents
- Nurse practitioners and physician assistants who have gone through different training and certification than doctors and may be primary care physicians in some practices
Original Medicare and primary care physicians
As mentioned above, if you have Original Medicare, you won’t need to choose a primary care physician. Medicare Part B will cover medically necessary services or certain preventive tests from Medicare-approved providers in office, hospital, or other settings. In most cases, you won’t need to get a referral to see specialists.
However, keep in mind that even though you may use any provider that is enrolled in Medicare, your costs will be lowest if you go to a doctor who accepts Medicare assignment. Accepting assignment means the physician agrees to accept the Medicare-approved amount as full payment for covered services. The provider also agrees to charge you only the Medicare deductible, copayment and/or coinsurance, if applicable.
Which doctors accept Medicare assignment?
Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:
- Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
- Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
- Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies; and you are responsible for the full cost of these benefits.
To find a participating doctor in your area, you can use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor's name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor's office.