Does Medicare Pay for a Second Opinion?

A second opinion involves seeking an evaluation from a doctor other than your primary healthcare provider regarding a diagnosis or proposed treatment plan. This offers a fresh perspective, helping to confirm an initial diagnosis or explore alternative treatments. It can foster confidence in significant healthcare decisions.

Medicare Coverage for Second Opinions

Medicare generally covers medically necessary second opinions under Medicare Part B. Part B typically covers outpatient services, including doctor visits. A second opinion is usually covered when a physician recommends it to confirm a diagnosis or treatment plan, especially before major medical procedures. Medical necessity means the service is required to diagnose or treat an illness or injury.

Criteria for Coverage

Coverage for a second opinion depends on the specific medical situation, such as when a doctor recommends surgery or a major procedure. Medicare Part B generally covers a second opinion before medically necessary, non-emergency surgery. If the first two opinions differ significantly, Medicare Part B may also cover a third opinion to resolve the discrepancy. This coverage extends to second opinions for serious or complex diagnoses.

Different parts of Medicare handle second opinions distinctly. Medicare Part A, which covers inpatient hospital care, typically does not cover doctor visits for second opinions. Medicare Part B addresses most outpatient services, including consultations for second opinions.

For beneficiaries in a Medicare Advantage Plan (Part C), coverage must be at least equivalent to Original Medicare. However, Medicare Advantage plans are managed by private insurers and may have specific rules, such as requiring referrals or limiting choices to in-network providers. Individuals with Medicare Advantage plans should consult their plan details for specific coverage requirements.

Steps to Obtain a Covered Second Opinion

Securing a second opinion covered by Medicare involves several steps. Your initial doctor can often provide a referral, which can streamline the process. For Original Medicare Part B, a formal referral is not always required. Choose a healthcare provider for the second opinion who accepts Medicare assignment. This means the provider agrees to accept the Medicare-approved amount as full payment, ensuring maximum coverage.

Before your appointment, have your medical records sent to the second opinion doctor. This avoids repeating tests and ensures the new doctor has all necessary information. You may need to ask your current doctor’s office to send these records or pick them up yourself. If the second doctor determines additional tests are necessary, Medicare may help pay for those, provided they are medically justified.

Understanding Costs and Denials

Even when Medicare covers a second opinion, beneficiaries are responsible for certain out-of-pocket costs. For Original Medicare Part B, this includes the annual deductible, which is $240 in 2024. After meeting the deductible, you are responsible for 20% of the Medicare-approved amount for the second opinion visit and any related tests. These cost-sharing requirements are consistent with most other covered medical services under Part B.

There are situations where a second opinion might not be covered by Medicare. Coverage will be denied if the service is not medically necessary or if it pertains to a service Medicare never covers, such as cosmetic surgery. If a second opinion claim is denied, beneficiaries have the right to appeal the decision. The appeals process begins with a reconsideration, followed by potential hearings if the appeal is not granted at earlier stages. Understanding these aspects and appeal rights allows beneficiaries to navigate their healthcare decisions.