Finding a Medicare Primary Care Physician near You
Last Updated : 06/20/20194 min read
You might be familiar with the term “primary care physician” from your employer-sponsored health plan. When you’re new to Medicare, you may ask, “how do I find a Medicare primary care physician near me?”
What does a primary care doctor do?
A primary care physician is the medical professional who generally oversees your health care, wellness visits, and preventive care.
If you get sick, you generally see your primary care physician first. If you need specialist care, your primary care doctor may refer you to the specialist.
According to the U.S. National Library of Medicine, a primary care provider (PCP) could be:
- A generalist doctor who specializes in internal medicine or family practice
- Nurse practitioners with training in adult care or geriatrics
- Other practitioners
Will I have to find a primary care doctor near me?
Not all types of Medicare coverage require a primary care doctor. If you enroll in Original Medicare (Part A and Part B), you generally don’t need to choose a primary care doctor but you still may wish to. You can see any doctor who takes Medicare patients, although your out-of-pocket costs will be lower if you use a doctor who accepts Medicare assignment. Medicare assignment is an agreement that the doctor will accept the Medicare-approved amount as payment in full, and won’t charge you anything besides the deductible or coinsurance, if applicable.
Medicare generally covers doctor visits in most medical settings, such as in the doctor’s office, in the hospital or outpatient department, in a nursing facility, or at an approved health clinic.
If you enroll in a Medicare Advantage plan, you may need to select a primary care physician. Medicare Advantage Health Maintenance Organization (HMO) plans and many Special Needs Plans (SNPS) require each person to have a primary care doctor. Medicare Advantage Preferred Provider Organizations (PPOs) and Private Fee-For-Service (PFFS) plans typically do not require members to choose a primary care physician.
Medicare Advantage is another way to receive your Original Medicare benefits through a private insurance company. Medicare Advantage plans must cover everything that Original Medicare covers, except of hospice care, which is still covered by Medicare Part A.
How do I find primary care doctors near me?
Your Medicare Advantage plan typically sends you a list of doctors that participate with the plan. The list usually includes not only primary care doctors, but also specialists, hospitals, pharmacies, and outpatient facilities contracted with the plan. Of course, if you have a medical emergency, you should get care from the closest appropriate provider, regardless of network.
If you enroll in a Preferred Provider Organization, or PPO, you may still get a list of doctors in your plan network. While you typically don’t have to choose a primary care doctor or get your routine care from providers within the plan’s network, you might pay less out of pocket when you see network providers.
What happens if I can’t find a primary care physician near me?
In most cases, your Medicare Advantage plan will have several participating physicians within the plan’s service area. If you already have a doctor and he or she doesn’t contract with your plan, you may need to switch to a doctor in your plan’s network.
If you can’t find a primary care doctor near you, contact your plan for help. Also, keep in mind that plans may change their provider networks from time to time. A doctor who participated last year may choose not to participate this year.
Many Medicare Advantage HMO plans require a referral from your primary provider before they pay for tests or specialist care, even from providers within the plan network. If your plan requires a primary care referral and you don’t get one, the plan may not pay, even if the specialist service would otherwise be covered.
To find a Medicare Advantage plan in your area, enter your zip code on this page.
Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether the plan will cover out-of-network service, you or your provider are encouraged to ask for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
A Private Fee-For-Service plan is not Medicare Supplement insurance. Providers who do not contract with the plan are not required to see you except in an emergency.