How Do I Keep My Primary Care Provider When Switching to Medicare?

Your primary care provider, or PCP, is responsible for addressing most of your healthcare needs. They are also the person who refers you to a specialist, should you need one. So, choosing the right PCP for your Medicare Advantage plan is essential.

What Is a Primary Care Provider?

You know you need one, but what is a primary care provider? They’re the person you go to for your general care needs, like a cold, a rash, an abscess, or stomach cramps. 

For any non-emergency medical issue, you’ll typically see your PCP first. If needed, they’ll refer you to a specialist for radiology, obstetrics, orthopedics, etc.

Most primary care providers are doctors (MDs or DOs), but they can also be physician’s assistants (PAs), nurses (RNs), or nurse practitioners (NPs). A doctor has to have an MD, DO, or equivalent medical degree.  Whereas both NPs and PAs are required to have a master’s degree, only NPs are allowed to work entirely independently from doctors.

If you’re on the Medicare Advantage Plan, you will usually need a referral from your PCP to see a specialist. That means you may pay out-of-pocket for your visit and any medications if you don’t have a referral.

Does a Medicare Advantage Require a Primary Care Provider?

Yes, Medicare Advantage plans are most often HMOs and generally require you to have an in-network PCP. Urgent care and dialysis outside of your area and all emergency services are exceptions to this rule.

There are other particular circumstances where going outside of the network is permissible. It’s called a Point of Service, or POS, option. Check your plan to confirm that you’re covered before you make an appointment out-of-network.

If you have a medical emergency, you should get help right away. It’s a good idea to learn beforehand which hospitals your plan covers. However, in an emergency, it’s not always easy to recall details. Go to the hospital first and worry about the details later.

You can get Medicare Part B benefits without a Primary Care Provider. The doctor you decide to see must have a Medicare assignment agreement in order for Part B to cover their services. This agreement means the doctor’s office has agreed to accept payment at Medicare Part B rates.

How Do I Find a Primary Care Provider?

There are nearly a half-million primary care doctors practicing in the United States as of March 2020. That’s a lot of providers to sort through. But, with a few simple guidelines, it can be simple to find one that’s right for your Medicare Advantage Plan.

The PCP you choose depends on three main factors:

• Whether or not you already have a primary care doctor.
• What type of Medicare plan you have.
• What kind of provider you want.

Keeping Your Current Primary Care Provider

Suppose you already have a relationship with a primary care provider. In that case, you may be able to continue with them when you switch to a Medicare plan. You should start by finding out if they take Medicare. If they do and you are on or considering Original Medicare (fee-for-service Medicare), with or without a Medicare Supplement (Medigap) plan, you should be able to continue with them without any additional considerations.

If, however, you are on or are considering a Medicare Advantage plan, you’ll need to make sure that your PCP is in network. Just ask them and they should be able to tell you. You can also ask your Medicare agent for help. 

Ask the provider directly. They should be aware of which insurance plans they are in-network with and which they aren’t.

If your doctor is in-network and decides to leave the network, your plan will notify you. When that happens, you’ll have the chance to choose a new provider.

If your doctor doesn’t know, or you want to verify that they’re in your plan, you can search your plan’s provider list. 

Finding a Provider on Medicare.gov

The official government site for Medicare has a lookup tool, if you want to see who’s in your local area. It’s also a helpful tool to use if you don’t already have a provider in mind. 

The search tool used to be known as “Provider Compare,” but Medicare.gov updated the site to combine all of their compare tools.

Enter your ZIP code, pick a provider type, and enter any keywords you need. Keywords can be something like “Celiac” or “Alzheimers” if you need providers who can treat those conditions. You can also enter the name of your current provider in the keyword field.

After the providers’ list comes up, you can narrow this list down by gender and distance from your house. Click the heart icon next to the doctors you want to save and the compare button to compare that doctor with others on the list.

Finding the Right Provider for You

When you’ve found a few doctors you’re interested in, there are some questions you should ask. First, find out if the provider is accepting new patients. Sometimes doctors have more patients than they can comfortably treat and choose not to take more.

Check out the doctor’s office hours to make sure they’re open when you’re most likely to want to see them. If the only opening in your schedule is Sundays, make sure the doctor can see you on Sundays.