Medicare Part B provides coverage for second opinions for some surgeries or complex medical conditions. It is essential to consult with a healthcare professional about coverage for specific procedures or services.
A second opinion involves a person getting another doctor’s input on a health issue or ahead of an intensive procedure. This can help people seeking medical care to make a fully informed decision about the benefits and risks of any planned treatments. It can also assist in confirming a diagnosis.
Second opinions may unnecessarily delay time-sensitive emergency surgeries, but they can support and empower an individual in non-emergency scenarios.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers a second opinion if a doctor recommends medically necessary non-emergency surgery. However, they will not fund second or third opinions ahead of procedures that are unnecessary to treat a condition, such as cosmetic surgery.
Getting a second opinion may also be advisable ahead of major nonsurgical diagnostic or therapeutic tests. Even if Medicare does not pay for the final procedure, it will still cover the second or third opinion unless the procedure is an excluded service.
Coverage for second opinions falls under Medicare Part B, which covers outpatient treatment such as consultations and other doctor services.
Likewise, any outpatient surgery that follows the second opinion, in which a person can return home the same day, would also come under Part B.
Medicare Part A would cover 100% of any in-hospital surgeries that require an overnight stay or longer following the second or third opinion.
If a person has chosen a Part D plan, this will cover any medications the doctor recommends that Medicare has approved. Different Part D plans cover different drugs and pharmacies.
People with a Part C plan, also known as Medicare Advantage, need to contact their insurance provider to see what specific benefits are available for second or third opinions. The coverage may differ from policy to policy.
Learn more about the parts of Original Medicare.
Medicare pays 80% of the costs for the services that Part B covers, with an individual paying the remaining 20% of the amount that Medicare approves. This part of Medicare also covers any related and relevant tests involved in confirming the second opinion.
Some people in a Medicare-managed care plan, such as a Health Maintenance Organization (HMO), may need a referral from their first doctor for a second opinion to qualify for coverage. In this instance, the named doctor in the referral is most often the one who will need to provide the second opinion.
However, a person first has to meet the annual deductible, which is the amount they have to pay out-of-pocket before Medicare starts to pay costs for the year. For 2024, the deductible for Part B is $240.
If a person has a regular doctor who has recommended treatment, they will need to source a different doctor for a second opinion.
People have several avenues through which they can find a second doctor, including:
- Asking their current doctor for recommendations: They should be able to provide the names of other doctors who could give a second opinion.
- Asking another trusted medical professional: Those uncomfortable with approaching their current doctor can speak to another doctor they trust.
- Speaking to local medical societies: These can provide the names of doctors in the area who deal with a person’s specific medical condition or injury. The local library may be able to identify the most appropriate local medical society.
- Calling the Medicare carrier that administers a person’s Medicare Part B plan: A person can call the Medicare carrier on 1-800-633-4227 (1-800-MEDICARE), or 1-877-486-2048 if a person has a hearing or speech impairment. The Medicare carrier can provide the names of local doctors who accept the Medicare-approved amount as full payment, which can save money. This is known as “accepting assignment.”
Learn more about contacting Medicare by phone.
If the first and second opinions are different, Medicare Part B will also pay for a third opinion.
Sometimes, a person may seek a confirmatory consultation even if the first and second opinions are the same. Medicare may pay for a third opinion in these instances if the doctor submits the claim correctly and the services are medically necessary and reasonable.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare pays for 80% of the costs of a second opinion for medically necessary, non-emergency surgical, diagnostic, or therapeutic procedures as part of a Part B plan. If the first and second opinions disagree, Medicare may also fund a third opinion for confirmation.
A person can speak with their current doctor, local medical societies, or Medicare provider to identify other doctors who can provide a second or third opinion.