How Do I Change my Primary Care Doctor on Medicare?
Summary: Some Medicare Advantage plans asks that you select a primary care doctor. Changing to a new primary doctor is typically an easy process of filling out a change form online with your insurer or calling member services.
A primary care doctor acts as your health care gatekeeper. This is the physician who oversees your medical care and makes referrals when you need diagnostic tests or specialist care.
Depending on whether you’re enrolled in Original Medicare (Part A and Part B) or a Medicare Advantage plan, you may need to choose a primary care doctor.
With some plans, if you get tests, medical therapies, or treatment from a specialist without a referral from your primary care doctor, your insurer may not pay for the services. It’s important to know your plan rules about when and how to choose a primary care doctor to keep your out-of-pocket costs as low as possible.
Do I have to choose a primary care doctor if I have Original Medicare?
If you are enrolled in Original Medicare, you generally don’t have to choose a primary care doctor. However, it’s important to make sure the doctor who manages your health care accepts Medicare assignment to keep your out-of-pocket costs low.
A primary care doctor has three options for caring for Medicare patients:
- Become a participating provider, which means accepting Medicare reimbursement rates as payment in full
- Become a non-participating provider, which means accepting Medicare patients but not Medicare reimbursement rates as payment in full
- Opt out of Medicare entirely
If you see a primary care doctor who participates with Medicare, you only need to pay 20% of Medicare’s allowable charges once your Part B deductible is met. If you choose a non-participating primary care doctor, your provider can charge you 15% more than the Medicare reimbursement rate.
Do I need a primary care doctor if I have Medicare Advantage?
If you’re enrolled in a Medicare Advantage HMO (Health Maintenance Organization) plan, you will have to select a primary care doctor within the plan’s network to oversee your care and refer you to specialists.
If you have a Medicare Advantage Preferred Provider Organization (PPO), you usually aren’t mandated to select a primary care doctor, but you do need to see network physicians to pay the lowest out-of-pocket costs.
How do I choose a primary care doctor?
Most Medicare Advantage plans publish a directory of network providers including primary care doctors. You can often get information about the doctor’s credentials, areas of practice, and even patient reviews from your plan’s directory. If the information you want isn’t available through the insurer, check the provider’s website to learn more about the doctor and practice.
You can also visit the Federation of State Medical Boards and search a doctor to see his credentials and find out whether there are any actions against him. Your state medical board may have additional information about any potential malpractice claims.
There are also third-party doctor review sites such as HealthGrade.com and RateMDs.com and Yelp where patients can leave reviews on primary care doctors they like or dislike.
What if I want to change my primary care doctor?
Once you choose a primary care doctor, changing to a new primary provider is typically a matter of filling out a change form online with your insurer or calling member services.
Do I need a primary care doctor for my Medicare Supplement Insurance Plan?
Medicare Supplement Insurance Plans help cover your out-of-pocket costs with Original Medicare. Once Medicare approves payment for a medical service or device, your plan pays your share of the deductible or coinsurance amount based on plan benefits.
Note that Medicare Supplement (Medigap) Insurance Plans only work with Original Medicare. You can’t buy Medigap if you have Medicare Advantage. Your benefits also don’t cover your expenses with a Medicare Part D Prescription Drug Plan.
Finding a good primary care doctor can help you get the best care for your health needs. If you’re unsatisfied with your primary care doctor, finding a better one for your needs might be a good investment in your long-term health.
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Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.
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