How do I check if my doctor takes my Medicare plan?

01Original Medicare: No Network

Original Medicare, Part A plus Part B, has no network. You can see any doctor, specialist, or hospital in the country that accepts Medicare. No referrals. No prior plan approval.

Most doctors accept Medicare, but a small number have opted out. If your doctor opted out, Medicare will not pay and you pay full cost. Always confirm your doctor accepts Medicare.

02Medicare Advantage: Networks Matter

Medicare Advantage, or Part C, comes from private insurers. Most plans have a network of contracted doctors, hospitals, and providers.

HMO plans usually require you to stay in network except for emergencies, often require a primary care doctor, and usually need referrals for specialists. Prior authorization is common, meaning the plan approves certain services before you get them.

PPO plans offer more flexibility. You can go out of network but pay more. Referrals are not always needed. The trade off is often higher premiums and cost sharing than HMO plans.

03How to Check If Your Doctor Is Covered

Do not rely only on the doctor office saying they take your insurance. Verify the details.

First, use the plan provider directory. Search by doctor name, specialty, or location. Confirm your specific doctor is listed, not just the practice. Doctors in one practice can have different network status.

Second, call the plan. Directories can be out of date. Call member services on the back of your plan card. Give the doctor full name and your plan name and ID. Ask them to confirm in the system.

04If Your Doctor Is Not in Network

You can switch to an in network doctor. Ask your current doctor for a recommendation or ask the plan for a list in the same specialty.

You can check out of network coverage. PPO plans often cover it at higher cost. HMO plans usually do not, except emergencies. Read your plan Evidence of Coverage.

You can ask for a continuity of care exception. If you are mid treatment, such as chemotherapy, some plans let you keep your doctor for a limited time while you transition. You must request it and get approval.

05Referrals and Prior Authorization

HMO plans usually need referrals from your primary care doctor to see specialists, and prior authorization from the plan for services like MRIs, surgeries, or certain drugs. Original Medicare needs neither for most services.

Make sure prior authorization is approved before you get the service. Without it, the plan may deny the claim and you may owe full cost. Your doctor office usually handles the request, but follow up to confirm approval before your appointment.

If authorization is denied, you can appeal. The denial letter explains why and how. Ask your doctor to help by providing records showing medical need.

06Tips for Keeping Your Doctors

List every doctor you see: primary care, specialists, dentist, eye doctor, therapists. Include practice names and phone numbers. Update it when things change.

Check the list against your plan every fall before December 7. If a doctor is leaving, you have time to switch plans.

Before any procedure, confirm network status for everyone involved, especially for surgery where the surgeon, anesthesiologist, hospital, and lab may bill separately.

07Getting Help

Your state SHIP program offers free, unbiased help. In North Carolina, it is called SHIIP. Counselors can help you check networks and compare plans. You can also call 1-800-MEDICARE or a local licensed insurance agent to check your doctors against plan networks.

The key point: with Original Medicare, you can see any doctor who accepts Medicare. With Medicare Advantage, the network decides who you can see and what you pay. Check before you enroll, and check again every fall.

This article is general information only. It is not personal advice or a recommendation about any specific plan.

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