Finding a Medicare Primary Care Physician near You
This article was updated on: 09/16/2018
Are you wondering how to find a primary care physician (PCP) near you? Whether you need a primary care doctor may depend on the type of Medicare coverage you have.
If you have Original Medicare (Medicare Part A and B), then you don’t need to choose a primary care physician. In general, you can see any health care provider, but your costs are lower if you get care from a Medicare-approved primary care physician who is accepting new patients. However, some types of Medicare Advantage plans require you to see a primary care doctor before you see a specialist.
Learn about situations when you may need to have a PCP and how to find a primary care physician near you.
What is a primary care physician?
For certain types of health plans, such as Health Maintenance Organizations (HMOs), your primary care physician is the doctor you usually first see about a health problem. He or she helps you get the right care and may talk with medical specialists about your case and refer you to them. Usually, you’ll receive primary care in an outpatient setting, like a doctor’s office or clinic. Often, a primary care physician will be involved in your medical care for a long time, and having a primary doctor may give you a trusting, ongoing relationship with one medical practitioner for a while.
Usually, a primary care physician’s role is to:
- Offer preventive care and advice on living a healthy lifestyle.
- Treat common medical conditions.
- See what medical problems are urgent and direct you to the right place for care.
- Make referrals to medical specialists when needed.
Types of primary care physicians
In the past, people relied on doctors for the health care of their entire family. Modern-day primary care physicians have brought this tradition back by helping patients maintain their overall health. There are different types of primary care doctors:
- Family practitioners who treat children and adults of all ages
- Internists who treat adults of all ages for many different medical problems
- Geriatricians who treat people with medical needs due to aging
- Obstetricians/gynecologists who often serve as a primary care physician for women, especially those of childbearing age
- Pediatricians who treat newborns, infants, children, and adolescents
- Nurse practitioners and physician assistants who have gone through different training and certification than doctors and may be primary care physicians in some practices
Original Medicare and primary care physicians
As mentioned above, if you have Original Medicare, you won’t need to choose a primary care physician. Medicare Part B will cover medically necessary services or certain preventive tests from Medicare-approved providers in office, hospital, or other settings. In most cases, you won’t need to get a referral to see specialists.
However, keep in mind that even though you may use any provider that is enrolled in Medicare, your costs will be lowest if you go to a doctor who accepts Medicare assignment. Accepting assignment means the physician agrees to accept the Medicare-approved amount as full payment for covered services. The provider also agrees to charge you only the Medicare deductible, copayment and/or coinsurance, if applicable.
Medicare Advantage plans and primary care physicians
If you have a Medicare Advantage plan, which is an alternative way to receive your Original Medicare benefits (except for hospice care that is still provided by Part A), you may need to choose a primary care physician for some types of plans.
The chart below displays some of the different types of Medicare Advantage plans and whether you need a primary care doctor.
|Medicare Advantage plan type||Do you need a primary care physician (PCP)?|
|Health Maintenance Organization (HMO) plans||Yes, in most cases, you need to choose a PCP.|
|Preferred Provider Organization (PPO) plans*||No|
|Private Fee-for-Service (PFFS) plans||No|
|Special Needs Plans (SNPs)||In most cases, yes, or the plan may require a care coordinator to help with your health care.|
Depending on your plan, you may have to choose a primary doctor from a list of medical professionals that are within the plan’s network. For other types of plans, such as Preferred Provider Organizations (PPOs)*, you have the option to seek health-care services outside of the plan’s network, but you may have to pay an additional cost. You can always contact your Medicare Advantage plan directly for more information about the provider network available to you. Please keep in mind that the plan’s provider network may change at any time. Should you enroll in a Medicare Advantage plan and there is a change in the provider network, you’ll receive notification of the change from the plan when necessary.
How to find a primary care physician near you
If your Medicare Advantage plan requires a primary care physician, you may want to take the time to find the right one. To get started, it’s a good idea to look at the list of providers within your plan’s network, since this may affect whether your costs and, depending on the plan, which doctors you can use. You can also ask friends, family members, or co-workers for personal referrals to a primary care physician in your area. If you’re moving, you can also ask your current primary care physician to help you find another one in your new neighborhood.
You can always contact Medicare at 1-800-MEDICARE (TTY 1-877-486-2048) 24 hours a day, seven days a week, if you’re trying to find out if a doctor accepts Medicare. The Medicare website, www.Medicare.gov, also offers a Physician Compare tool that allows you to find doctors in your area. Alternatively, you can call a nearby doctor’s billing department to learn this information.
As you can see, the type of Medicare plan option you select may require you to choose a primary care physician. If you have questions about Medicare plan options that accept your primary care doctor or want help finding coverage, please feel free to let me know by scheduling a phone interview or having me email you personalized information using the links below. You can learn more about me by clicking the “View profile” link below. If you want to compare plan options on your own, please use the Find Plans or Compare Plans buttons on this page.
For more information about primary care providers, see:
U.S. National Library of Medicine, “Choosing a Primary Care Provider,” last updated August 2015, https://www.nlm.nih.gov/medlineplus/ency/article/001939.htm
*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 we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.