Many doctors do accept people with Medicare, but there may be some out-of-pocket costs to consider.
Medicare is very well established and has built an extensive network of healthcare providers since its inception.
In 2017, the American Academy of Family Physicians surveyed members about their participation in the Medicare program, and 83% of physicians reported that they accept new Medicare patients.
Today, most doctors do accept Medicare patients, and there are many ways to check if a healthcare provider is participating.
In this article, we look at finding a doctor and treatment costs, and for Medicare Advantage members, we look at information about in-network and out-of-network providers.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Assignment means that a doctor agrees to accept the Medicare-approved amount as full payment for covered health services and supplies.
The majority of doctors accept assignment. Participating health providers have an agreement with Medicare to accept assignment for all Medicare-covered services.
If the doctor accepts assignment:
- out-of-pocket costs may be less
- the doctor agrees to charge only the Medicare coinsurance and deductible, and the doctor will usually wait for Medicare to pay its share before billing an individual
- the doctor is required to submit the claim directly to Medicare, and the doctor cannot charge a person to file the claim
If a doctor accepts assignment, Medicare determines the amount the doctor will be paid for health services and supplies.
A doctor who does not have an agreement with Medicare to accept assignment is considered a non-participating provider.
It may be important for a person to note, however, that even though a provider may be non-participating, they may choose to accept assignment for some types of services.
What happens when a doctor is a non-participating provider?
If a healthcare provider does not have an agreement with Medicare, a person may be required to pay the entire bill at the time of service.
If the doctor is willing, they can submit a claim to Medicare directly for any Medicare-covered services they provide, but they cannot charge a person for submitting a claim.
Individuals may have to pay for a service and submit a claim themselves, using Form CMS-1490S for reimbursement.
Excess charges
Sometimes, a doctor can charge a person more than the Medicare-approved amount, creating an excess. The excess is any amount over the Medicare-approved cost.
In these cases, Medicare will not cover the excess, but some Medigap plans may help with these expenses.
Limiting charge
There is a limit to the amount a doctor can bill for a service, called a limiting charge. This means that doctors can charge up to a maximum of 15% more than the amount Medicare will cover.
The limiting charge applies to doctors who have chosen to accept Medicare for some services only. The charge does not apply to providers who are fully non-participating.
To find a doctor that accepts Medicare, a person can visit the Medicare Physician Compare site and search by location, and by entering either:
- the last name of the healthcare professional
- the group practice name
- medical specialty
- body part
- medical condition
The search results will then provide a list of participating professionals in the location specified.
Private medical insurance companies administer Medicare Advantage plans, also known as Medicare Part C. These are bundled health plans that offer an alternative to original Medicare.
Each Medicare Advantage plan has different rules for how a person may receive services, like whether a person needs a referral to see a specialist, and whether visiting an in-network healthcare provider must be used.
What is a provider network?
A provider network is a group of doctors, healthcare providers, and hospitals that a plan has a contract with, making them in-network.
A healthcare provider who has no contract with a plan is an out-of-network provider.
A private insurance company that offers Medicare Advantage policies may have different networks for different plans, so when a person searches for a healthcare provider online, it may be beneficial to ensure the correct plan is selected.
In-network providers can also be located by calling the insurer.
Seeing a specialist
Some Medicare Advantage plans have different rules for when a visit to a specialist is needed, such as:
Health Maintenance Organization (HMO) plans: Usually, a person is required to obtain a referral from their primary care physician to see a specialist under an HMO. Some services do not require a referral, such as a yearly mammogram screening.
Preferred Provider Organization (PPO) plans: A person does not normally need a referral to see a specialist under a PPO. If a person uses an in-network specialist, their costs for covered services may be lower than if they use an out-of-network provider.
Most doctors accept Medicare, and if they do not, they may still accept Medicare for certain services.
If a doctor accepts assignment, it means they have a formal agreement with Medicare to accept the Medicare-approved amount as full payment for all covered services.
A provider network is a group of healthcare providers who have contracted with a particular health plan to provide cost-effective care to its members, making them in-network.
To find a doctor that accepts Medicare, a person can visit the Medicare Physician Compare page.