Does Medicare Cover Second Opinions?

Seeking a second medical opinion can be a valuable step in making informed healthcare decisions, especially when facing significant medical recommendations. These consultations offer an opportunity to gain additional perspectives on a diagnosis or a proposed treatment plan. Understanding how Medicare covers such opinions is important for beneficiaries navigating complex health situations.

Medicare Part B Coverage

Medicare Part B generally provides coverage for second opinions. This part of Original Medicare helps pay for doctor’s services, outpatient care, and certain preventive services, which include consultations for second opinions. When a physician recommends surgery or a major diagnostic or therapeutic procedure that is not an emergency, Medicare Part B covers a second opinion from another doctor.

For coverage to apply, the doctor providing the second opinion must accept Medicare assignment. This means the doctor agrees to accept the Medicare-approved amount as full payment for services. Medicare Part B pays 80% of the Medicare-approved amount for the second opinion, and beneficiaries are responsible for the remaining 20% coinsurance after meeting their annual Part B deductible.

Determining Eligibility for Coverage

Eligibility for Medicare coverage of a second opinion hinges on “medically necessary” services. A second opinion is considered medically necessary if it relates to a procedure or service needed to diagnose or treat an illness, injury, or medical condition, and it meets Medicare’s established criteria. Medicare does not cover second opinions for services that are not medically necessary, such as cosmetic surgery.

In cases where the first and second opinions differ, Medicare Part B may also cover a third opinion. This allows beneficiaries to obtain further clarity when conflicting medical advice is received. If you are enrolled in a Medicare Advantage (Part C) plan, the rules for obtaining a second opinion may vary. While these plans are required to provide at least the same coverage as Original Medicare, they might have additional requirements, such as needing a referral from your primary care doctor or using a provider within the plan’s network.

Submitting Second Opinion Claims

When seeking a Medicare-covered second opinion, it is helpful to discuss this with your current doctor and request that your medical records be sent to the new physician. Providing the second doctor with comprehensive records can help avoid duplicate tests. You should confirm that the doctor providing the second opinion accepts Medicare to ensure coverage. Resources like Medicare.gov’s Care Compare tool or calling 1-800-MEDICARE can help locate such providers.

Under Original Medicare Part B, you will pay 20% of the Medicare-approved amount for the second opinion after your annual deductible has been met. If additional tests are ordered as part of the second opinion, Medicare will generally help pay for them if they are medically necessary. If a claim for a second opinion is denied, you have the right to appeal the decision. The appeals process begins with a redetermination, followed by reconsideration, and potentially further levels of review. Instructions for appeal are usually provided on the Medicare Summary Notice (MSN) you receive.