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Health Line
4 days ago
- Business
- Health Line
What to Do If Your Doctor Doesn't Take Medicare
If a doctor doesn't accept Medicare, you can choose to see them and pay more, or you can find a different provider. Medicare has an online directory of participating providers. When you're enrolled in Medicare and looking to get medical care, it's important to check whether the healthcare professional you want to see is willing to work with the insurance program. Many doctors work with Medicare. Those who do not may be nonparticipating providers or opt-out providers. Nonparticipating providers may sometimes accept assignment, but they may not at other times. Opt-out providers never accept Medicare. Read on to learn what to expect and what to do when your doctor will not take Medicare. What happens if a doctor doesn't accept Medicare? A doctor who works with Medicare is referred to as accepting assignment. This means the provider is willing to accept Medicare reimbursement. If you see a doctor who does not accept assignment, you'll have higher out-of-pocket costs than with a participating provider. In this case, your choices are as follows: See a different doctor: Switch to a different doctor who works with Medicare. Go to urgent care: Depending on your medical needs, you could schedule an immediate care or walk-in visit with a doctor who accepts Medicare. This may be easier and faster than scheduling a regular appointment. Most urgent care centers should accept Medicare. You can speak with the care center staff to learn whether the facility accepts Medicare. Proceed and pay extra: You might make this decision, for example, if you need to see a specific specialist and no similar specialist is accepting assignment. In this case, you can consider asking the staff if there are any discounts or payment plans that you might be eligible for. Submit claim: If you do proceed with seeing a nonparticipating doctor who does not accept assignment, they will submit a claim for any portion of the service they will directly bill to Medicare. In some cases, you may be asked to pay upfront and submit the claim yourself. How much does it cost to see a doctor who doesn't accept Medicare? Medicare nonparticipating providers can choose individually whether to accept the Medicare-approved rate for covered services. This amount is what Medicare reimburses them for services under Medicare Part B. If they do not accept this rate, they can charge you up to 15% more than the approved rate. The exact percentage varies by state and is called the 'limiting charge.' Note that this surcharge rule does not apply to durable medical equipment (DME), which means DME suppliers can charge more than the limiting charge. When it comes to opt-out providers, since they do not accept Medicare at all for any service, they will bill you directly for all costs unless you have a secondary health insurance plan that they do accept. Is it hard to find doctors who accept Medicare? It's not difficult to determine whether a doctor works with Medicare. To find out if a doctor accepts Medicare assignment, consider asking your current doctor's office for a referral to someone who does accept assignment. You can also use the Medicare provider directory on the website. Alternatively, you can call 800-MEDICARE (800-633-4227) or the specific doctor's office and ask before you schedule the appointment. In addition, representatives from the State Health Insurance Assistance Program (SHIP) may be able to assist you in the search. Why would a physician opt out of Medicare? Whether to accept an assignment depends on each doctor or clinic. Doctors who opt out of Medicare can set their own fees and avoid Medicare billing rules, audits, prior authorizations, and documentation requirements, gaining greater flexibility and reducing their administrative responsibilities. Nonparticipating providers, in particular, can decide on a case-by-case basis whether to accept Medicare rates or bill you directly at higher rates for certain services. In high cost areas or when their patients indicate that they can pay out of pocket, nonparticipating providers may earn more than participating providers when they don't accept assignment. On the other hand, when nonparticipating providers file a Medicare claim, they receive a payment that is 5% lower than the amount permitted by the Medicare physician fee schedule. This means they earn less than participating providers when they consent to accept assignment. Frequently asked questions What percentage of doctors do not accept Medicare? As of 2024, only about 1% of non-pediatric physicians had opted out of Medicare altogether, with psychiatrists leading at 8.1%. Opt-out rates are notably low for emergency medicine, oncology, radiology, and pathology, all at 0.1% or less. Psychiatrists, on the other hand, make up the largest portion of those opting out, followed by family and internal medicine physicians. As of 2024, only about 1% of non-pediatric physicians had opted out of Medicare altogether, with psychiatrists leading at 8.1%. Opt-out rates are notably low for emergency medicine, oncology, radiology, and pathology, all at 0.1% or less. Psychiatrists, on the other hand, make up the largest portion of those opting out, followed by family and internal medicine physicians. Do doctors have to accept Medicare Advantage plans? When considering nonparticipating versus opt-out providers, remember that these terms refer to doctors who may or may not accept Original Medicare (parts A and B). In addition, you have the option to enroll in a Medicare Part C (Medicare Advantage) plan instead, which would give you the same benefits. However, these are private insurance plans with their own network of providers. Depending on the type of plan, you may have to see an in-network provider. When considering nonparticipating versus opt-out providers, remember that these terms refer to doctors who may or may not accept Original Medicare (parts A and B). In addition, you have the option to enroll in a Medicare Part C (Medicare Advantage) plan instead, which would give you the same benefits. However, these are private insurance plans with their own network of providers. Depending on the type of plan, you may have to see an in-network provider. Why does Medicare pay less than the Medicare-approved amount? Every year, the Centers for Medicare & Medicaid Services (CMS) sets the rates for all physician services for the following year using a range of complex data sets and formulas intended to represent physician costs associated with practicing medicine, among other factors. That said, according to the American Medical Association, this formula does not adjust these rates for inflation, which may be another reason a doctor could decide to opt out of Medicare. Every year, the Centers for Medicare & Medicaid Services (CMS) sets the rates for all physician services for the following year using a range of complex data sets and formulas intended to represent physician costs associated with practicing medicine, among other factors. That said, according to the American Medical Association, this formula does not adjust these rates for inflation, which may be another reason a doctor could decide to opt out of Medicare. Do all doctors accept Medicare Supplement plans? Medicare supplement plans, also called Medigap, can be easily confused with Medicare Advantage. Doctors do not accept Medigap simply because it is not a medical insurance plan. Instead, Medigap helps cover remaining costs after Original Medicare coverage kicks in. Medicare supplement plans, also called Medigap, can be easily confused with Medicare Advantage. Doctors do not accept Medigap simply because it is not a medical insurance plan. Instead, Medigap helps cover remaining costs after Original Medicare coverage kicks in. Takeaway When you are enrolled in Original Medicare and need medical attention, it's crucial to verify whether the healthcare professional you wish to visit collaborates with the insurance program. Numerous doctors partner with Medicare, but some may not. Per Medicare guidelines, they are referred to as nonparticipating providers or opt-out providers. Nonparticipating providers might occasionally accept Medicare assignment, while opt-out providers never do. If a doctor does not accept Medicare, you have the option to still see them, but you will likely incur higher costs. You can also see a different provider. Medicare provides an online directory listing participating providers.
Health Line
4 days ago
- Business
- Health Line
What Happens After Enrolling in Medicare?
After you enroll in Medicare, you receive a welcome packet with information such as your Medicare card. You also have some important decisions to make about additional coverage. It's a great idea for a new Medicare enrollee to learn how Medicare works and the interactions of its parts. Consider familiarizing yourself with the key parts of Medicare: Part A (hospital insurance) Part B (medical insurance) Part C (Medicare Advantage) Part D (prescription drug coverage) Medicare supplement insurance (Medigap) With a solid understanding of the Medicare system, you can make educated decisions and ensure that your coverage aligns with your health and financial goals. Medicare can be complex. If you want help understanding your options and deciding what's best for you, consider speaking with a professional. You can get free, unbiased Medicare counseling from your local State Health Insurance Assistance Program (SHIP). This article discusses what to expect in the weeks after signing up for Medicare and what steps you can take to get the best coverage. Look for your welcome packet Within a couple of weeks of signing up for Medicare, you receive a ' Welcome to Medicare ' packet that contains a: letter introducing you to the Medicare program booklet with your coverage details Medicare card Your Medicare number is on your Medicare card and account. Healthcare professionals, insurers, and certain government agencies require your Medicare number to identify you and ensure you get the appropriate care. You also need your number to join a Medicare plan and buy Medicare supplement insurance. Consider your coverage needs Once you sign up for Original Medicare (parts A and B), you can decide whether to add additional coverage. Your options include: switching to a Medicare Advantage plan adding Part D prescription drug coverage including Medicare supplement insurance (Medigap) Medicare Advantage plans are available from private insurance companies. These plans include the same benefits as Original Medicare but offer extra coverage for other medical necessities, such as dental, vision, and hearing care. Medicare Advantage plans vary by location and provider. You can search for and compare plans on If you want to keep Original Medicare, you have a few options for adding extra coverage. You can sign up for a stand-alone Part D plan to add coverage for prescription drugs. You can also sign up for a Medigap plan to help cover the out-of-pocket costs of Original Medicare. Consider signing up for a Medigap plan within 6 months after your Part B coverage begins to get the most plans at the best prices. Learn when your coverage begins Knowing when your coverage starts is critical after enrolling in Original Medicare. The timing of your coverage initiation depends on when you sign up. If you sign up for Medicare during your initial enrollment period but before the month of your 65th birthday, your coverage begins at the start of your birth month. If you sign up during or after the month you turn 65 years old, coverage begins at the start of the next month. Once your coverage begins, consider contacting your healthcare professionals and pharmacy to update them on your new insurance. Schedule your 'Welcome to Medicare' visit If you sign up for Medicare Part B, you qualify for a 'Welcome to Medicare' preventive visit during your first 12 months of coverage. It's a free, comprehensive visit that includes: a review of your health history educational material on vaccines and other preventive services body measurements necessary referrals a mental health evaluation a written medical plan However, the Welcome to Medicare visit isn't a physical. Get familiar with your coverage Review your policy documentation to understand all facets of your coverage when you finalize your plans. Look at what benefits you can receive, the costs you need to pay, and the coverage limitations. Doing so can help you get the most out of your Medicare coverage and prepare for costs ahead of time. Summary After enrolling in Medicare, you receive some vital information. You also have to make some decisions about your coverage. Watch for your Medicare welcome packet in the mail and review its documents. Read up on how Medicare works to help you make coverage choices that are right for you. Once you finalize your coverage, update your healthcare professionals on your new insurance details, and schedule your Welcome to Medicare preventive visit, if you have Part B. Contact your local SHIP for free Medicare counseling if you have questions.
Health Line
13-05-2025
- Health
- Health Line
Medicare Nonparticipating Providers: What You Should Know
A Medicare nonparticipating provider is a healthcare professional, facility, or supplier that doesn't accept Medicare assignment in all cases and may charge more than the Medicare-approved amount for certain services. When a healthcare professional accepts Medicare assignment, it means they agree to charge the Medicare-approved amount for all medically necessary services. Nonparticipating providers don't agree to these terms. While they still accept payment from Medicare, they may charge more for covered services. As a Medicare enrollee, receiving healthcare services from a nonparticipating provider has certain drawbacks. Learn more about what nonparticipating providers are and what to consider when getting care. Understanding Medicare assignment For Medicare billing purposes, there are three primary types of healthcare professionals: participating providers who accept Medicare assignment nonparticipating providers opt-out providers When a healthcare professional, facility, or equipment supplier 'accepts assignment,' it means they agree to charge the Medicare-approved amount for all services covered by Original Medicare (Part A and Part B). These providers can only bill Medicare enrollees for the deductible and coinsurance amounts. On the other end of the spectrum are opt-out providers. These providers don't participate in Medicare at all. If you receive services from a provider who opts out of Medicare, you must pay the full cost — except in emergencies. Nonparticipating providers are the middle ground. They may accept assignment in some cases, but they may also charge more than the Medicare-approved amount. Medicare nonparticipating providers Medicare nonparticipating providers can decide whether to accept the Medicare-approved amount for covered services on a case-by-case basis. If they don't accept the Medicare-approved amount, they can charge up to 15% more than the approved amount. This is called a limiting charge. The limiting charge amount can vary by state. In New York, it's 5%. Limiting charges may apply to services covered by Part B, but they may not apply to durable medical equipment (DME). Suppliers of DME may charge more than the limiting charge. When nonparticipating providers submit a claim to Medicare, Medicare pays them 5% less than the amount allowed under the Medicare physician fee schedule. This means nonparticipating providers get paid less than participating providers when they agree to accept assignment. At the end of each calendar year, physicians can decide whether to change their Medicare participation status or leave it as is. You can search for healthcare professionals in your area and learn whether they accept assignment using the provider search tool on Considerations when using a nonparticipating provider If you anticipate contacting a healthcare professional who is a nonparticipating provider, there are a few things to consider. Up-front payment Participating providers typically bill Medicare before asking people to pay a deductible or coinsurance amount. Nonparticipating providers may have you pay the full cost up front. Then, they submit a claim to Medicare on your behalf for any covered services. If a provider files your claim, you typically receive a Medicare summary notice that includes reimbursement for covered services or equipment. The reimbursement is 80% of the Medicare-approved amount for services covered under Part B. Limiting charges You typically pay more when receiving care from a nonparticipating provider, as these providers can charge up to 15% more than the Medicare-approved amount for covered services. Some states have rules governing how large this limiting charge may be. While a typical Medicare coinsurance is 20% of the Medicare-approved amount, if a person uses a nonparticipating provider with a 15% limiting charge, they are responsible for paying this 15% on top of their 20% coinsurance. Summary Medicare nonparticipating providers may choose to accept Medicare assignment on a case-by-case basis. This means they may charge up to 15% more than the Medicare-approved amount for covered services. The disadvantages of using a nonparticipating provider include paying higher costs for covered services, paying up front for care, and waiting for reimbursement. The downside for providers is that when they accept assignment, Medicare pays them 5% less than participating providers. You may wish to factor potential higher costs into the equation when deciding whether to get care from a nonparticipating provider.
