Can I keep my own doctor with Medicare?
With Original Medicare, almost always. With an Advantage plan, it depends on the network, and networks change every January.
This is usually the question that decides which path someone takes, and the answer is different depending on which path you are asking about.
With Original Medicare
You can see any doctor, specialist or hospital in the United States that accepts Medicare. There is no network and no referral requirement. The overwhelming majority of physicians accept Medicare.
There are two categories worth knowing:
- Participating providers accept Medicare assignment, meaning they take Medicare's approved amount as full payment. This is most doctors.
- Non participating providers accept Medicare but can charge up to 15 percent above the approved amount, called an excess charge. Some Medigap plans cover that, some do not.
- Opt out providers have withdrawn from Medicare entirely and bill you directly. Rare, and concentrated in a few specialties like psychiatry and concierge practices.
So with a supplement, the practical answer is yes, keep your doctor, and it will keep being yes if you move or travel.
With Medicare Advantage
Now it depends on the plan's network, and that is a real question rather than a formality.
- HMO plans generally require you to stay in network and to get a referral to see a specialist. Out of network care is usually not covered except in an emergency.
- PPO plans let you go out of network at a higher cost, so you have flexibility, you just pay more for it.
Before enrolling, check your specific doctors against that specific plan for that specific year. Not the carrier generally. The plan.
The part that catches people every January
Networks are not permanent. A doctor or a hospital system can leave a plan's network at the end of a plan year, and a plan can drop a provider group.
Check your doctors every fall during Annual Enrollment, even if you are happy and not planning to change anything. The plan you keep may not have kept your doctor. This is the single most common unpleasant surprise in January.
If your doctor leaves mid year, you generally cannot switch plans in response. That is not a qualifying event. You wait for October. See what to review during Annual Enrollment.
How to actually check
- Call the doctor's billing office directly and ask whether they are contracted with the exact plan name for the coming year, not just the carrier.
- Ask about the hospital they admit to as well. A doctor in network who admits to an out of network hospital is a problem waiting to happen.
- Check the plan's own provider directory as a second source, understanding that directories are frequently out of date.
- Do this again every fall.
Asking the front desk whether they take a carrier is not enough. Carriers run many different plans and a practice may accept some and not others.
The honest summary
If keeping a specific doctor matters more than anything else, Original Medicare with a supplement removes the question permanently. If your doctors are solidly inside a good local network, an Advantage plan gives you more benefits for less monthly cost.
Here in South Texas the networks are deep, which is why so many people do well on Advantage plans. It is still worth verifying rather than assuming. See the full comparison of both paths.
Common follow-up questions
My doctor says they take Medicare. Does that mean they take my Advantage plan?
No, and this mix up is common. Taking Medicare and being contracted with a specific Advantage plan are two different things. Ask about the plan by name.
What if my doctor leaves the network mid year?
You generally have to wait until Annual Enrollment to change plans. A provider leaving the network is usually not a qualifying event for a special window.
Do I need a referral to see a specialist?
Not with Original Medicare. Usually yes with an HMO Advantage plan, usually no with a PPO.
Want this looked at properly?
We are an independent agency in McAllen serving Hidalgo, Cameron and Starr counties. No cost to talk it through.
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Medicare Annual Enrollment in South Texas: dates, rules and what to do
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