When researching Medicare plans, individuals can consider which doctors or healthcare facilities nearby accept Medicare. Several online tools can help locate a Medicare-approved doctor.
Medicare has a range of plans for healthcare coverage that many doctors, clinics, and hospitals accept.
Choosing the best Medicare plan for a specific location will grant a person access to a network of doctors and hospitals that accept Medicare payments. Selecting a suitable plan may also help a person reduce out-of-pocket expenses.
It is each person’s responsibility to verify that their particular Medicare plan covers specific healthcare services. The person must confirm coverage before any treatment, as the hospital does not confirm coverage on their behalf.
This article explains how to check which doctors near you accept Medicare.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The official Medicare website provides resources and tools for finding local doctors and healthcare services that accept Medicare.
These services include:
- dialysis facilities
- home health services
- long-term care hospitals
- inpatient rehabilitation facilities
Medicare provides a Service Coverage tool that an individual can use to check whether their Medicare plan covers a test, item, or service.
The Centers for Medicare and Medicaid Services (CMS) provides a simple tool called Physician Compare.
A person can enter their ZIP code, and the tool will display a list of doctors and healthcare facilities in the areas that accept Medicare plans.
People can also search by a healthcare professional’s last name, the practice name, or the medical specialty they require.
To filter the search, a person can select:
- how far from their location they want to search
- the sex of the clinician they feel most comfortable visiting
- whether they are part of a group or running a solo practice
- their board certification status
The doctors listed on Physician Compare accept Medicare, but the tool does not provide information about secondary insurance, such as Medicaid.
An individual will need to contact their secondary insurance provider to make sure their preferred doctor accepts the terms of their plan.
Learn more about Medicare coverage for doctor visits.
Private insurance companies provide some Medicare plans, including Medigap and Medicare Advantage (Part C).
If an individual has a privately administered Medicare service, they should ask their insurance provider about local doctors who accept payments from this coverage.
Insurance companies usually have a limited network of doctors, hospitals, and healthcare services that accept their payments.
People can find an insurance company’s customer service phone number or website in their enrollment documents or search for them online.
An individual could ask neighbors and other people who live in their area and who have Medicare about the healthcare services they use.
Internet forums and other websites can also provide relevant information.
When a person is considering a new healthcare professional, they can contact the office directly to find out if the medical professional accepts Medicare.
Healthcare professionals have to choose to opt into Medicare. When they do this, they agree to accept Medicare as full payment and accept its terms.
However, doctors can also choose to opt out of Medicare. This may be because they charge higher amounts for their services.
The most effective way to find a specialty doctor in a certain area is by using the Medicare Compare tool.
This tool allows a person to search for a healthcare professional using their ZIP code and the doctor’s specialty.
It is important to keep in mind that many Medicare Advantage plans require a referral from a primary care physician for specialists.
Medicare parts
- Original Medicare (parts A and B): Original Medicare includes both parts A and B. It is provided by the federal government and covers most standard hospital and outpatient care.
- Medicare Part C: Medicare Part C (Medicare Advantage) is a bundled alternative to Original Medicare. It is provided by Medicare-approved private insurance companies and offers the same coverage as Original Medicare, as well as prescription drug coverage (Part D) and other benefits.
- Medicare Part D: Medicare Part D helps cover the cost of prescription drugs.
Read more about Medicare Part A, Part B, Part C, and Part D.
Not checking key information with a healthcare professional or facility before receiving care can make it so that the individual has to pay more if the medical professional or facility does not meet Medicare’s requirements.
When looking for a new medical professional it is important to remember to check criteria, such as whether they accept the assignment and the coverage network of a specific plan.
Accepting assignment
When a healthcare professional accepts the assignment from Medicare, they agree to accept the Medicare-approved amount as full payment for treatments and services.
Individuals may wish to check whether a medical professional accepts the assignment for any required services and treatments.
Coverage network
Since Original Medicare parts are provided by Medicare, there is no coverage network or service area limit. This means people with Original Medicare can use any healthcare professional or hospital that accepts Medicare anywhere in the United States.
However, Medicare Advantage (Part C) plans have different rules about which healthcare professionals and facilities individuals can use.
For example, some Medicare Advantage plans may have specific networks or service areas of medical professionals and facilities.
Some Medicare Advantage plans may allow people to use out-of-network providers but this may have higher costs.
| Medicare Advantage plan type | Out-of-network physicians and facilities rules |
|---|---|
| Health Maintenance Organization (HMO) | Only for out-of-area dialysis, emergency care, or urgent care |
| HMO Point of Service (HMO-POS) | Sometimes. A plan may cover limited out-of-network services if an individual pays a higher copayment or coinsurance. |
| Preferred Providers Organization (PPO) | Yes, but out-of-pocket expenses are typically higher. |
| Private Fee-for-Service (PFFS) | Yes, but out-of-pocket expenses are usually higher. |
| Special Needs Plan (SNP) | No, unless the SNP plan is a PPO-style plan. |
| Medicare Savings Account (MSA) | Yes, individuals can use any Medicare-approved physician or facility. This is generally without higher costs. |
If a person has a Medicare Advantage plan, they can contact their insurer for more information about the plan’s network. Individuals can also check their plan’s rules for out-of-network care and services.
An individual can accept services from any healthcare professional. However, a doctor who does not accept Medicare may have higher rates.
If a person does not verify their Medicare coverage for a particular healthcare service, they may be responsible for the full amount.
Doctors who accept Medicare will charge a specially negotiated rate. Doctors must opt-in for Medicare and agree to accept their plans as payment for services.
Opting into Medicare means that they agree to the service terms set by the Federal government.
Learn how Medicare reimburses healthcare providers.
With Original Medicare, an individual can choose any Medicare-enrolled doctor, healthcare professional, clinic, or hospital.
Some Medicare Advantage plans require that an individual choose a primary care physician (PCP) from the network of providers. However, an individual can change their PCP at any time by contacting the insurance provider.
Most insurance companies have an online portal for selecting a new PCP, and they provide a list of approved local doctors who accept someone’s particular Medicare Advantage plan.
Insurance companies can change their provider network as they choose and at any time.
If an insured person’s primary care doctor leaves the provider network and the individual does not wish to change doctors, they have several options.
Change between Medicare Advantage plans
If an individual finds that their PCP is part of another Medicare Advantage plan’s provider network, they can change to this plan during:
- the open enrollment period, which is from October 15 to December 7
- the Medicare Advantage open enrollment period, which is between January 1 and March 31
Leave the plan
A doctor may leave all Medicare Advantage networks but continue to accept Medicare. In this case, an individual can change to Original Medicare and receive coverage to see that particular doctor.
An individual with a Medicare Advantage Plan can make this change during the open enrollment period or Medicare Advantage open enrollment period.
Change plans during the special enrollment period
The special enrollment period allows individuals to switch to another plan due to certain circumstances, such as:
- moving to a new address outside the current plan’s service area
- having the chance to get other coverage
- losing employer-provided health insurance
A person typically has 60 days before or after the event to enroll in the new plan.
Changes to the provider network may trigger the special enrollment period. This may occur due to changes in the contract between the CMS and the plan provider.
Alternatively, they may not renew the contract or may reduce the size of its service area.
If this happens, the plan provider will contact the individual. They can then enroll in a different Medicare Advantage plan or Original Medicare.
Find out about the different enrollment periods.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
There are various sources that can help a person find a doctor near them who accepts Medicare. These include the Medicare website, the Physician Compare tool, and insurance company provider information.
Not every doctor accepts Medicare. It is up to the individual to check that the doctor accepts Medicare, or they may need to pay costs in full.
It is worth taking the extra step to verify that a doctor accepts Medicare coverage. This can help ensure a person gets the most from their Medicare benefits and keep out-of-pocket expenses to a minimum.
