I recently helped a Medicare client who was facing the prospect of a pretty significant surgery and wanted to pursue getting a second opinion. Thought I’d share some of the basics of what we learned about Medicare’s Coverage of Second Opinions…….
Let’s start by setting a foundation. Generally, a second opinion is when you request that another qualified physician (in addition to your treating doctor) provide their view about your health issue (e.g., symptoms, an injury, or an illness you are experiencing) in order to better help you make an informed decision about what’s the best course of treatment for you.
Medicare’s coverage rules hold that getting a second opinion can help you make a more informed decision about your care and course of treatment. When your doctor says you have a health problem that needs surgery (or a major diagnostic or therapeutic procedure), you have the prerogative to have another qualified physician look at those choices with you (second opinion), the prerogative to know and understand your treatment choices, and the prerogative to participate in treatment decisions by making your wishes known.
Bottom line when it comes to Medicare benefits and second opinions is this: Medicare’s benefits cover second opinions if a doctor recommends that you have surgery, or a major diagnostic or therapeutic procedure, and that recommended course of treatment is a Medicare covered service.
*Note that Medicare does not cover second opinions for services that are excluded and are not normally covered by Medicare (e.g., cosmetic surgery). Regardless of the type of Medicare coverage you have (Medicare Supplement Plan or Medicare Advantage Plan), all Medicare coverage provides for a second opinion as a covered benefit in the same way that it covers other services that are recognized as medically necessary under Medicare.
If you have Original Medicare and a Medicare Supplement Plan, second opinions are covered just like any other service under Part B. For example, if you have Supplement Plan G and you’ve already met the annual Part B deductible ($226 in 2023), then between Medicare Part B and the Supplement Plan, the second opinion would be covered at 100%.
If you have a Medicare Advantage Plan, second opinions are covered just like any other Specialist. You will pay the cost-sharing (co-pay) that applies to specialist physician services under your specific plan. Remember to use a participating network provider for the second opinion. For those beneficiaries that are enrolled in an HMO plan that requires referrals, you may need to obtain a referral from your Primary Care Physician (PCP) in order for the second opinion to be covered by your plan.
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