When Does Medicare Cover Second Opinions?

Curated by Claudia Shannon / Research Scientist / ishonest

Sometimes you need to get a second opinion on a diagnosis or treatment plan that your doctor gives you. The good news is Medicare will provide coverage when you do.

You can use Medicare Part B or your Medicare Advantage plan to get coverage. As long as it’s a service that Medicare typically covers, you’ll be covered.

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Medicare will also cover you if both doctors disagree and you need to get a third opinion.

When does Medicare cover second opinions?

You can get coverage for a second opinion using Medicare.

This often happens when your doctor thinks you need surgery to help treat a condition. You can see a different doctor to get a second option on whether the surgery is necessary.

Medicare will pay for you to see the other doctor and get a second opinion so you can make an informed choice.

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The only time Medicare won’t pay for a second opinion is if the surgery is one that Medicare never covers. In this case, Medicare wouldn’t cover the second opinion or the surgery.

Most surgeries are covered by Medicare as long as they’re medically necessary.

Surgery is considered medically necessary if it’s being used to treat a condition or to prevent one from getting worse. Surgery isn’t considered medically necessary if it’s cosmetic.

Which parts of Medicare cover second opinions (and what are the rules)?

You can get coverage for second opinions in a few different ways.

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If you’re enrolled in Medicare parts A and B, together known as original Medicare, you’ll use Part B for coverage. Medicare Part B is the part of original Medicare that covers services like doctor’s office visits. This coverage includes second opinions.

Medicare Part A is hospital insurance and doesn’t cover doctor visits. When you use original Medicare for your second opinion, you’ll pay 20 percent of the Medicare-approved cost. Medicare will pay the other 80 percent.

You also have coverage options with some of the other parts of Medicare. Cover for second opinions under other Medicare parts includes:

  • Part C (Medicare Advantage). Medicare Advantage plans cover everything that original Medicare does, including second opinions. However, you might need to see a doctor who’s part of your plan’s network or get a referral from your primary care doctor.
  • Part D. Medicare Part D is prescription drug coverage. It doesn’t cover doctor visits at all. So, it won’t provide coverage for second opinions.
  • Medicare supplement (Medigap). Medigap covers the out-of-pocket costs of using original Medicare. It doesn’t provide additional coverage — which means it won’t cover a second opinion, but you can use it to lower your cost when you get one.

How much do second opinions cost?

Your costs will depend on the part of Medicare you’re using and whether you’ve already paid any deductible associated with your plan. Some costs you might see include the following:

  • When you use original Medicare. You’ll need to meet your deductible before Medicare will start to cover your costs. The deductible in 2020 is $198. After you meet it, you’ll pay 20 percent of the cost of your appointment.
  • When you use Medicare Advantage. Medicare Advantage plans have their own prices and costs. Check the details of your plan to see if you have a deductible and what your copayment or coinsurance amount is.
  • When you use Medigap. Your costs with Medigap will depend on your plan. Some Medicare plans include coverage for the Part B deductible, while others include coverage only for your coinsurance payments.

What are the eligibility requirements for Medicare to cover a second opinion?

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Medicare will cover your second opinion as long as it’s about a service that Medicare covers. Medicare will cover most services, but there are a few it never covers. These services include:

  • alternative medicine
  • cosmetic surgery
  • most dental care
  • hearing aids
  • custodial care
  • long-term care
  • nonemergency transportation
  • routine foot care
  • vision care

Medicare won’t provide coverage if you need a second opinion about one of the services listed above. However, as long as your service is something Medicare does cover, you can get a second opinion with Medicare.

If you’re not sure whether a service is covered, you can search for it on the Medicare website.

What is a second opinion?

A second opinion is when you have a doctor review a diagnosis or treatment plan that another doctor gave you.

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Second opinions can help you understand your options and make sure you’re getting the right care. For example, you might seek a second opinion to see if surgery is really the best option to treat your condition.

Talk with your doctor when you want to get a second opinion. You can ask them to send your medical records over to the second doctor.

It’s a good idea to arrive at your appointment prepared with a list of questions for the second doctor. At your appointment, tell the second doctor what treatments or surgery the first doctor recommended.

The second doctor will review your records and examine you. They might order different tests than your first doctor did. Medicare will pay for any additional tests you need.

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Sometimes the second doctor will come to the same conclusion as your first doctor. In other cases, you might get a different answer.

There are a few steps you can take if the second doctor gives you a different diagnosis or recommends a different treatment. Depending on what the doctor says you can:

  • Go back to the first doctor and talk to them about what the second doctor said.
  • Get treatment from the second doctor.
  • Get a third opinion from another doctor.

Medicare will provide coverage if you need a third opinion. The rules will be the same as when you got your second opinion.

When you might consider a second opinion

You can get a second opinion when you’re not feeling sure about a diagnosis or treatment plan from your doctor. It’s important to feel comfortable with a treatment plan your doctor has recommended.

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If you feel that a diagnosis or treatment isn’t right, don’t be afraid to get a second opinion. It can be a good idea to get a second opinion when:

  • Your doctor’s treatment plan involves surgery or another high-risk procedure.
  • You’ve been diagnosed with a rare condition.
  • You’ve been diagnosed with cancer.
  • You’ve been on a treatment plan for an extended period of time, with no changes to your condition.

Emergencies are exceptions. During a medical emergency, you should get care from the doctor treating you. For example, don’t wait to get a second opinion if a doctor says you need emergency surgery for a blood clot or ruptured appendix.

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