Does Medicare Cover a Urologist?
- Learn about Medicare coverage for a urologist's care, and find out how out-of-pocket costs vary depending on whether you receive inpatient or outpatient care.
Urologists are physicians who specialize in diagnosing and treating conditions that affect the bladder, urinary tract, kidneys, adrenal glands and male reproductive system. If your primary care physician has recommended that you see a urologist, Medicare is likely to cover at least some of the cost.
Does Medicare Cover a Urologist?
Medicare pays for medically necessary care from specialists like urologists. Which part of Medicare will pay and how much of the cost you'll be responsible for depends on where you see a urologist.
Do I Need a Urologist?
Urologists see men, women and children who are experiencing new symptoms or have chronic conditions that a primary care physician doesn't have the expertise to treat. Your doctor will advise you if you need to see a urologist. They may also recommend a specific physician who focuses on a certain area of urology, such as pediatrics or women's health.
What Conditions Do You See a Urologist For?
Urologists diagnose and treat many general conditions, including:
- Frequent urinary tract infections (UTIs)
- Urinary incontinence that a primary care physician can't diagnose or manage
- Bladder cancer
- Kidney stones
- Kidney failure
In addition, urologists provide treatment for conditions that affect only women or men, such as:
- Bladder prolapse, a condition where the bladder drops into the vagina
- Enlarged prostate and prostate infections
- Erectile dysfunction
- Low testosterone in men
- Male infertility
- Prostate and testicular cancers
- Lumps in the scrotum
- Testicular pain
- Peyronie's disease, a buildup of tissue that causes the penis to become curved
Does Medicare Require a Referral to See a Specialist?
If you are enrolled in traditional Medicare, you usually don't need a referral to see a specialist; however, a urologist may not be willing to see you unless your primary care physician has recommended treatment.
Whether you'll need a referral under Medicare Advantage Plans (Medicare Part C) depends on what type of insurance you have:
- Health Maintenance Organization (HMO) plans usually require a referral
- Preferred Provider Organization (PPO) plans typically don't require a referral
- Private Fee-for-Service (PFFS) plans normally don't require a referral
- Special Needs Plans (SNPs) plans generally require a referral
When Does Medicare Part A Cover a Urologist?
Medicare Part A covers care from a urologist that occurs while you're hospitalized. For example, if you were rushed to the hospital and admitted for the treatment of kidney stones, Medicare A would likely pay for the services the urologists at the hospital performed. If your deductible is not met, you will need to pay it before coverage begins. Depending on the length of your stay, you may be responsible for coinsurance fees.
When Does Medicare Part B Cover a Urologist?
Medicare Part B covers outpatient care from a urologist, provided that the physician accepts Medicare. Under Medicare Part B rules, you usually pay for 20% of the cost, and Medicare pays for the rest. You'll typically have to satisfy your deductible before Medicare coverage begins.
When Do Medicare Advantage Plans Cover a Urologist?
If you have an all-in-one Medicare Advantage plan, coverage for outpatient treatment from a urologist varies on insurance type:
- HMOs, PPOs and SNPs usually cover the cost of in-network urologists. Out-of-network doctors may be covered in some cases, but you'll usually have to pay more out of pocket.
- PPFS plans don't always have networks. If yours does, you'll pay less when you see a participating urologist.
With any type of Medicare Advantage plan, you'll likely have to pay copays or coinsurance for outpatient urology appointments.
How Do I Find a Urologist Who Accepts Medicare?
Medicare offers a search tool to help you find participating physicians who accept Medicare. Enter your geographic location, choose "doctors & clinicians" from the drop-down menu and then type "urologist" in the keyword area. If you have a Medicare Advantage plan, your insurance provider likely offers a network search tool.