Does Medicare Pay For Second Opinions Before Surgery?

Medicare Part B medical insurance will pay most of the cost for a second opinion in some cases. But there are certain criteria that have to be met.

Medicare will also cover its portion of the costs for additional tests the second doctor orders and any other services that are medically necessary.

If the first and second opinions are different, Medicare will also pay most of the costs for a third opinion.

If both opinions are the same, Medicare will sometimes still pay for a third doctor to make a confirmatory consultation. But the doctor will have to submit the claim properly, and Medicare has to determine that the doctor’s services were necessary and reasonable.

Medicare does not cover surgeries or other procedures, such as cosmetic surgery, that are not medically necessary. It also will not pay for second opinions for procedures that are not medically necessary.

Medicare Advantage plans may have different rules or coverage for second and third opinions. Check with your plan’s administrator to determine specifics before seeking a second opinion.

You are responsible for your Medicare Part B deductible and 20 percent of the Medicare-approved cost of the second opinion.

The same out-of-pocket costs apply if you are eligible to seek a third opinion.

A Medigap (Medicare Supplement) insurance plan may cover some of your out-of-pocket costs for a second opinion — including a portion of your deductible, coinsurance and any copayment.

Medicare Advantage plans are required to cover anything Medicare Part A and Part B covers, but your plan may provide additional coverage or benefits when seeking a second opinion.

Medicare Advantage and Medigap plans are sold by private insurers. Coverage and benefits vary from plan to plan so it’s important to contact your plan’s administrator to find out exactly what is covered if you seek a second opinion.

When a doctor tells you that you have a health condition that requires surgery — and it’s not an emergency — you may want to consider a second opinion. A second opinion can help you make a better-informed decision about how to treat your health problem.

If you need emergency surgery — for an aneurysm, blood clots, acute appendicitis, injuries from an accident or any other life-threatening emergency — you should not wait for a second opinion.

Before scheduling an appointment for a second opinion, be sure the doctor accepts Medicare. Medicare can help you find a doctor for a second opinion.

You can also ask your first doctor or another doctor you trust to recommend another doctor who can give you a second opinion. It’s best to choose a doctor from a different office or practice.

Once you’ve scheduled your second opinion appointment, you’ll need to make certain arrangements. This will make it easier and quicker for you to get your second opinion.

If you have a Medicare Advantage plan, you may have to get your second opinion from a doctor in your plan’s network. If you go to a provider who is out of your plan’s network, you may have to pay more. Check with your plan’s administrator to determine what your plan requires.