Getting a Second Opinion: Cost, Process and Coverage

A second opinion is billed as a visit with another clinician, so what you pay depends mostly on your plan's network, referral and deductible rules rather than on the fact that it is a second look. A few programs go further: Original Medicare covers, in some cases, a second and, when opinions differ, a third opinion before non-emergency surgery, and Medicaid managed care plans must arrange a second opinion at no cost to the enrollee.

Key takeaways

Original Medicare Part B covers, in some cases, a second opinion for medically necessary, non-emergency surgery, and a third opinion if the first two differ; after the $283 Part B deductible for 2026, you pay 20% of the Medicare-approved amount.
Medicaid managed care plans must provide a second opinion from a network provider, or arrange one outside the network, at no cost to the enrollee.
In the illustrative PPO example below, the same visit costs $60 in network and $280 out of network once the balance bill is added, and federal surprise-billing rules do not cover an office visit you book yourself.
California requires the health care service plans it regulates to provide or authorize second opinions in listed situations, but state insurance rules do not reach self-funded employer plans.
Your first doctor's office may send your records to the second doctor for treatment without your authorization, and you also have a federal right to your own copy within 30 days, for a cost-based fee.

What counts as a second opinion

Medicare describes a second opinion as another doctor giving their view about your health problem and how it should be treated. The second doctor reviews your diagnosis and the proposed treatment, usually with your records and test results in hand.

For billing, the second opinion is a visit with a clinician like any other, and any new tests that clinician orders are separate services. That is why your plan's ordinary rules on networks, referrals, prior authorization and deductibles usually decide the cost, unless one of the specific rules below applies.

Coverage by type of plan

The table summarizes the rules that apply by default. Your own plan documents, such as the Evidence of Coverage or the Summary Plan Description, decide the details.

Coverage	Is a second opinion covered?	What usually decides your cost
Original Medicare (Part B)	In some cases, for medically necessary, non-emergency surgery; a third opinion if the first two differ	Part B deductible, 20% coinsurance, whether the doctor accepts assignment, and any Medigap or other supplemental coverage
Medicare Advantage	Plans must cover all medically necessary services Original Medicare covers, but set their own network, referral and prior-authorization rules	Plan copay or coinsurance; out-of-network rules differ by plan type (HMO or PPO)
Medicaid managed care	Yes; the plan must provide one in network or arrange one outside it	No cost to the enrollee under the federal rule
Medicaid fee-for-service	The federal second-opinion rule applies to managed care plans	Check with the state Medicaid agency
Fully insured employer or individual plan	The plan's ordinary specialist-visit rules, unless a state law adds more (California's is described below)	Network status, referral or prior authorization, deductible and copay
Self-funded employer plan	Set by the plan document; state insurance mandates do not apply	Network status and the plan's own rules
Uninsured or self-pay	Not applicable	The provider's price; you can get a good faith estimate

Original Medicare

According to Medicare's second surgical opinion page, Part B covers, in some cases, a second opinion for medically necessary surgery that is not an emergency, and a third opinion when the first two differ. Tests the second doctor orders as a result of the visit are covered like other medically necessary services. The rule is written around surgery, so a second opinion on another question is handled like any other Part B doctor visit.

After the Part B deductible, which CMS set at $283 for 2026, you pay 20% of the Medicare-approved amount. Your share also depends on the doctor's billing status: as Medicare explains, a doctor who accepts assignment takes the Medicare-approved amount as full payment.

A non-participating doctor who does not accept assignment can charge more than the approved amount, in many cases up to 15% more (the "limiting charge"), and may ask you to pay the full amount at the visit. Medicare's guide to Medicare Advantage plans notes that Medigap, or coverage from a current or former employer, a union or Medicaid, can help pay the 20% coinsurance. Medigap plans sold to people new to Medicare on or after January 1, 2020, cannot cover the Part B deductible.

Medicare Advantage

The same Medicare guide says plans must cover all medically necessary services Original Medicare covers, but you may need to use network doctors, get a referral to see a specialist, or get the plan's approval in advance. You, your representative or your doctor can ask the plan for an organization determination, a decision on whether a service will be covered and what you will pay. If an in-network provider refers you outside the network without getting that decision first, in most cases you will not pay more than the plan's usual cost sharing.

Medicaid managed care

Federal Medicaid managed care rules require states to make sure each plan provides for a second opinion from a network provider, or arranges one outside the network, at no cost to the enrollee (42 CFR 438.206). The rule applies to managed care plans within the services they are contracted to cover. The federal rule does not set out how to request one, so the member handbook is the place to check.

Private plans and state rules

Where no specific rule applies, a private plan handles a second opinion under the same network, referral and prior-authorization rules as any other specialist visit. Some states add their own requirements.

California's Health and Safety Code section 1383.15 requires health care service plans to provide or authorize a second opinion when an enrollee or a treating network clinician requests one for reasons that include doubts about recommended surgery or about a diagnosis or care plan for a serious condition. "Health care service plan" is a legal category: according to a 2003 California HealthCare Foundation brief, the Department of Managed Health Care regulates HMOs and some PPOs, while the Department of Insurance regulates indemnity plans and other PPOs. The section may not cover your plan.

Once the plan approves, the enrollee pays only the copay the plan charges for similar referrals. A second opinion about a primary care physician's care comes from a qualified clinician of the enrollee's choice in the same physician organization. For a specialist's care, the enrollee can choose any network medical group or independent practice association with the same or an equivalent specialty.

The plan must authorize a clinician outside the network only if no qualified participating clinician is available, and it must take into account the enrollee's ability to travel. A denial must be in writing, with the reasons and the right to file a grievance. Requests must be decided expeditiously, and when the enrollee faces an imminent and serious threat to health, within 72 hours of the plan receiving the request whenever possible. The section does not apply to certain PPO contracts that do not limit access to second opinions.

State insurance rules do not reach self-funded employer plans, where the employer pays claims itself and often hires an insurer only to administer them. A 1995 General Accounting Office report explains the reason: self-funded plans are not treated as insurance, so ERISA preempts state regulation of them, and many employees do not know which kind of plan they have. The Summary Plan Description or the HR benefits office can tell you.

Worked cost examples

The cost follows a simple structure. In network it is the copay, or the deductible and coinsurance; out of network, a balance bill may be added.

Your cost = deductible portion + coinsurance (or copay) + balance bill

deductible portion = the part of the allowed amount that counts toward an unmet deductible
coinsurance        = your percentage of the allowed amount after the deductible
allowed amount     = the price your plan (or Medicare) recognizes for the service
balance bill       = billed charge − allowed amount, when the provider is allowed to bill it

Illustrative example, Original Medicare. Assume a Medicare-approved amount of $250 for the consultation, no supplemental coverage, and that the Part B deductible for the year is already met.

Doctor accepts assignment: you pay 20% of $250, which is $50.
Doctor does not accept assignment and charges the full limiting charge: CMS explains that non-participating doctors are paid 95% of the fee schedule amount and may charge up to 115% of that. The approved amount is $237.50 and the limiting charge is $273.13. Medicare pays 80% of $237.50, or $190, so you pay $83.13, which is $33.13 more than with an assigned doctor.
Deductible not yet met: because $250 is below the $283 deductible for 2026, the whole $250 counts toward the deductible and you pay $250 at this visit.

The deductible is paid once a year, so within one calendar year the order of visits does not change your total. If you have $500 of other Part B care in the same year, your total is $376.40 whether the second opinion comes first or last. The year does matter: with $100 of other Part B care this year and $1,000 next year, the second opinion adds $196.40 to this year's costs but only $50 to next year's. Because a second opinion usually comes before a treatment decision, putting it off for billing reasons can also delay care, which is worth weighing before changing the timing.

Illustrative example, private PPO. Assume a $60 in-network specialist copay. An out-of-network specialist bills $400, the plan's allowed amount is $200, the out-of-network deductible is met, and out-of-network coinsurance is 40%.

In network: $60.
Out of network: 40% of $200 is $80, plus a balance bill of $400 − $200 = $200, for a total of $280.
Plan that pays nothing without authorization: you owe the full $400.

In this example the out-of-network visit costs $220 more than the in-network one. If the visit is not covered at all, the $400 bill is nearly seven times the in-network copay. Federal surprise-billing protections do not change this: CMS's guide to No Surprises Act rights for insured patients covers emergency care, non-emergency care related to a visit to an in-network hospital or surgical center, and air ambulance services, and says the protections do not apply in other settings such as a doctor's office that is not a hospital outpatient department.

Arranging a second opinion

Read the plan's rules first. Look up "second opinion", "referral" and "prior authorization" in your Evidence of Coverage or Summary Plan Description. Then call member services and ask whether a referral or authorization is needed, which in-network clinicians qualify, and what the visit will cost you.
Choose the second clinician deliberately. A useful second opinion usually comes from someone in the same specialty who does not practice with your first doctor. If no in-network clinician has the relevant expertise, ask the plan in writing to approve an out-of-network visit at in-network cost, and keep the reference number.
Get authorization in writing when one is required. A dated approval with a reference number is what you will need if the claim is later denied.
Move the records ahead of the visit. Send the diagnosis, the treatment recommendation, imaging reports and the images themselves, pathology reports, and recent lab results, so the second doctor does not need to repeat tests.
Ask for a written consultation report. The report is what you and your first doctor will compare against the original plan. California, for example, requires the plans covered by section 1383.15 to have the second clinician send one to both you and your first doctor.
Decide what happens if the two opinions disagree. Original Medicare covers a third opinion in that case before non-emergency surgery. Other plans vary, so ask before booking it.

Getting your records to the second doctor

There are two routes. The first is provider to provider: HHS confirms that HIPAA lets providers share records such as X-rays, lab and pathology reports for treatment without the patient's authorization, including to consult with other providers. The second doctor's office can ask your first doctor's office for them directly; follow up with both offices if they have not arrived.

The second route is your own copy. Under 45 CFR 164.524, you have a right to inspect and get copies of your records held by covered providers and health plans. The provider must act within 30 days of your request and may take one further 30-day extension only if it tells you in writing why and when it will finish. You can ask for an electronic copy of records kept electronically, and the fee for your own copy is limited to a reasonable, cost-based charge for copying labor, supplies and postage; psychotherapy notes are excepted.

Asking a provider to send a copy straight to a third party works differently. After a 2020 court ruling, HHS says the cost-based fee limit applies only to your request for your own records, not to a request to transmit them to someone else, and the right to direct a transmission covers electronic copies of records in an electronic health record. Getting your own copy first, or using the provider-to-provider route, avoids that gap.

When the plan says no

A denied referral, a denied authorization or a denied claim for the visit can be challenged. For private plans, HealthCare.gov's appeal guidance explains that you have 180 days from the denial notice to file an internal appeal, and that if the plan still denies it you can ask for an external review. In urgent situations you can request both at the same time.

Medicare Advantage plans must tell you in writing when they deny coverage, and Medicare's guide confirms your right to appeal; the plan's Evidence of Coverage sets out the steps. Medicaid managed care enrollees have 60 calendar days from the denial notice to appeal to the plan (42 CFR 438.402), and can request a state fair hearing once the plan upholds the denial, or sooner if the plan misses its notice and timing requirements. Original Medicare has its own separate appeals process.

A strong appeal is short and specific. It cites the plan's own rule on second opinions or out-of-network exceptions and, as HealthCare.gov suggests, includes supporting information such as a letter from the treating doctor. If you are asking for an out-of-network specialist, it also shows that no in-network clinician has the relevant expertise.

Self-pay and remote reviews

Some people pay for a second opinion themselves, either because they have no coverage, because the doctor is outside their network, or because they use a remote record-review service that does not bill insurance. If you are uninsured or choose not to use insurance, CMS's notice on good faith estimates says providers generally must give you one if you ask or schedule care at least three business days ahead.

That estimate carries weight later. According to CMS's dispute page, you can start a federal patient-provider dispute only if all of these apply: you did not have or did not use insurance and told the provider so before the care; the care was on or after January 1, 2022; you received the estimate three days before the scheduled appointment; the initial bill is dated within the last 120 calendar days; and one provider or facility billed at least $400 more than its own estimate.

The filing fee is $25 and is non-refundable, though it is deducted from what you owe if the dispute is decided in your favor. While the dispute is open, the provider cannot send the bill to collections. Before paying for a remote review, ask whether a clinician examines you or reviews records only, whether pathology or imaging is reread, and whether the fee covers a follow-up discussion.

Checklist before you book

Plan type identified: Original Medicare, Medicare Advantage, Medicaid, fully insured or self-funded employer plan, or self-pay.
Referral or prior authorization confirmed, with a reference number if one was given.
Second clinician's network status or Medicare assignment status checked directly with the office.
Expected cost written down: copay or coinsurance, remaining deductible, any balance bill, and what supplemental coverage pays.
Records on the way: a provider-to-provider transfer requested, or your own written request dated against the 30-day deadline.
Good faith estimate requested when you schedule, if you are paying without insurance, with the date you received it noted.
Plan for a third opinion agreed if the first two may disagree.

This article explains coverage and billing rules for general education and is not medical, legal or financial advice. Decisions about diagnosis and treatment belong with your clinicians, and plan-specific questions are best confirmed with your insurer or a licensed professional.