Medicare Annual Enrollment Period: October 15 - December 7

Are Doctors Required to Accept Medicare?

Whether your doctor accepts Medicare or not is dependent on their choice to participate in the Medicare program. We explain the differences, so you know what to look out for.
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If you are eligible for Medicare soon, you may want to know if there are enough doctors that accept Medicare. The quick answer is yes – many doctors accept Medicare patients.

You may also be wondering if doctors are ‘required’ to accept Medicare? Here, the answer is more complicated – it depends on their participation status and your Medicare coverage.

Here’s what you need to know.


Are doctors required to accept Medicare?

Research shows that 93% of non-pediatric primary care doctors accept Medicare. However, only 72% get new Medicare patients.

There are three different types or levels of Medicare participation that can designate health care providers.

  • Participating providers are doctors and other healthcare providers who accept assignments. They accept Medicare’s payment (plus Part B coinsurance) as full payment of their services. Therefore, there is no need for you to pay extra.These doctors accept whatever coverage you have. So, if you have Part B and Medigap, they will work with both. They cannot decline to work with specific Medicare regional offices or Medigap insurers.
  • Non-participating providers are still part of the Medicare program but can accept (or choose not to accept) Medicare patients depending on the case.Non-participating doctors are legally allowed to charge up to 15% above Medicare’s approved rate (minus what Medicare pays). As a patient, you are responsible for these ‘excess charges.’

    Good news: Some states have a limiting charge of 5%, which is the maximum amount that non-PARs can charge Medicare patients after the 20% coinsurance.

  • Opt-out providers don’t accept Medicare. They decide their rates; therefore, they don’t bill Medicare. With these doctors, you will pay their fees out-of-pocket in full.

Therefore, whether doctors accept Medicare or not depends on their participation status.

If you want to get a list of nearby Medicare doctors, you can browse online directories like Zocdoc or Yelp. You can also ask your current doctor if they accept Medicare. You may also ask for referrals from family, friends, and co-workers.

If you are enrolled in a Medicare Advantage (MA) plan, also known as Part C, you should visit your insurer’s website to learn what doctors are covered by your plan.


If your doctor ‘accepts’ Medicare, who pays for their services?

Medicare pays for doctor’s fees of Part A (hospitalization) and Part B (medical).

  • Those under Original Medicare usually get supplementary insurance like Medigap. What is Medigap coverage used for? Medigap pays for out-of-pocket costs like deductibles, coinsurance, and copayments.

Under Medigap, your doctor gets paid by both Medicare and Medigap. Medicare pays them first, with the remainder of the payment covered by your Medigap plan. Since Medigap plans are simply insurance coverage covering your out-of-pocket costs, doctors cannot decline one and accept the other.

Doctors under a Medicare Advantage plan’s network have separate contracts with private insurers. Therefore, they are not paid directly by Medicare.


Do you need to file claims?

If you are insured under Original Medicare, you may have to complete claim filing for reimbursement if your doctor does not handle claims. You have one year to submit your claim before getting reimbursed. Check your Medicare Summary Notices (MSN) regularly for details.

Under a Medicare Advantage plan, your insurer submits claims directly to Medicare.


Why don’t some doctors accept Medicare?

Firstly, it is not mandatory for doctors to accept Medicare. However, many do. Doctors can practice medicine even if they don’t take Medicare patients. They only need to be registered with CMS.

Another reason is the flexibility to charge higher fees. Opt-out providers are free to decide how much they will charge patients. Non-participating doctors, on the other hand, can only charge up to 15% more than the Medicare-approved rates. Participating providers (those who accept assignment) can charge no more than the Medicare-approved rates.

A third reason is to avoid the administrative burden. Many doctors prefer to be paid directly by patients instead of completing paperwork before getting paid.

Data shows that the states with the highest opt-out rates are Alaska, Colorado, and Wyoming. Specialists most likely to opt out include psychiatrists, plastic/reconstructive surgeons, and neurologists.


What should you expect if your doctor doesn’t accept Medicare?

Under this circumstance, you will pay for your doctor visit out-of-pocket at full cost. Your doctor will ask you to sign a contract stating that Medicare is not paying them for your treatment.

If your doctor accepts Medicare, but your treatment is not covered, there is no need to sign a contract. However, you still need to pay in full. A good example is visiting an audiologist to get hearing aids (and your health insurance plan does not offer coverage for this type of service).

A Medigap plan may also be a good option for you to help to manage your out-of-pocket costs.


Are doctors required to accept Medicare if you have a Medigap plan?

Medigap is a supplementary type of coverage that pays for out-of-pocket costs under Original Medicare – deductibles, copayments, and coinsurance.

Doctors who participate in Medicare must treat patients under Medigap, just as they treat any patient who only had Medicare Parts A and B.

Plus, Medigap Plan F and Plan G cover the excess charges of non-participating physicians.


Still deciding between a Medicare Advantage plan vs. a Medigap plan?

One difference to keep in mind is your access to doctors.

Under a Medicare Advantage plan, you know that doctors in that plan’s network are required to accept Medicare – so there is never any doubt that you will have access to doctors.

However, with Original Medicare, while many doctors accept Medicare, they can change their participation status. Your current participating doctor can opt out (or decide to change to non-participating). So, you may need to switch doctors.

Another consideration is the cost.

If you are under Original Medicare (and are not covered by Medigap plans F of G), you may have to pay excess charges if your doctor is non-participating.

With Part C, however, there is no risk of excess charges.

You may also want to consider other factors in deciding between a Medicare Advantage plan or a Medigap plan.


In summary

Now that you know whether doctors are required to accept Medicare or not, and the different types of Medicare participation, you will have more confidence in selecting the Medicare plan that is right for you.

The CoverRight team is always here to help review the doctors available in your area and help you select the right new plan.


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