Transitioning to Medicare is a significant milestone, but much of it can feel like uncharted territory, especially when it comes to questions regarding healthcare providers. Finding a physician you can trust is important for your health and well-being, which is why it’s essential to know whether Medicare covers these expenses.
Discover the essential steps you must take to ensure you continue receiving the care you need from your trusted healthcare providers as you transition to Medicare.
Do All Doctors Accept Medicare?
Unfortunately, though Medicare is a federal program, not all doctors accept it. Healthcare providers have the choice to opt out providers of Medicare, and some often do because of factors like reimbursement rates, certain coverage rules, and challenging paperwork processes.
Generally, most doctors do accept Medicare approved amount, but it’s always a good idea to confirm before scheduling a visit. Most doctors can participate in Medicare covered services in a few different ways:
- Participation (PAR) Agreement: Participating providers accept Medicare and agree to the program’s payment terms. Participating providers also accept the Medicare-approved amount as full payment for covered services.
- Non-Participation (non-PAR) Agreement: Non participating providers accept Medicare but can make decisions on a case-by-case basis and bill patients accordingly. In this instance, Medicare patients may have to pay the entire bill at the time of service to non participating provider, but a claim can still be submitted to Medicare to cover any excess charges.
- Private Contracting /Opt-Out Providers: These doctors bill patients directly and forgo any Medicare approved payments. In this case, they claim Medicare patients pay for services out-of-pocket after determining a set cost for the patient’s bill.
Remember that doctors are not obligated to accept Medicare. However, because Medicare is a widely used program, most doctors participate in it. Either way, it’s important to check with your physician before receiving care to ensure you aren’t liable for any medical expenses.
Can You Keep Your Current Doctor When You Are On Medicare?
Keeping your current doctor when transitioning to Medicare depends largely on the type of Medicare plan you choose and whether your doctor participates in Medicare.
Keeping Your Doctor Under Original Medicare
With Original Medicare (Medicare Part A and Medicare Part B), you can visit any doctor, specialist, participating provider, or hospital that accepts Medicare. Because there are no network restrictions, you have broad access to healthcare providers nationwide.
If a provider accepts Original Medicare, they must also accept your Supplemental plan (Medigap). This helps cover out-of-pocket expenses. Since Medigap works alongside Original Medicare, it doesn’t limit your choice of doctors, provided they accept Medicare.
You should always confirm with providers whether they accept Medicare Assignment, meaning they agree to Medicare’s approved reimbursement rates as payment in full. There are two types of doctors who claim Medicare: those who participate in the fee-for-service system, referred to as “assignment doctors,” and those who do not, known as “non-assignment doctors.” Non-assignment doctors can add an “excess charge” to your bill, up to 15% above Medicare’s standard reimbursement rate.
If your doctor does not take Assignments, you might consider selecting a Medigap policy that will cover excess cost. Only two options provide this coverage: Plan F and Plan G. Plan F is being phased out and is only available to those born before January 1, 1955. Thus, Plan G is a good option to cover excess charges if your doctor doesn’t take Assignments.
It’s also important to highlight that doctors who typically do not accept new Medicare patients often maintain their commitment to seeing their existing patients who transition to Medicare as long as there is a strong foundation of trust and an established relationship in place.
Keeping Your Doctor Using a Medicare Advantage Plan
Medicare Advantage (Part C) plans are administered by private insurance companies and often include provider networks. Depending on the type of plan, keeping your current doctor may depend on whether they are part of the network.
Advantage Plans typically do not require premiums, offering a “pay-as-you-go” approach instead. This means you will only pay co-pays when you visit doctors until you reach your maximum out-of-pocket limit for the year.
Enrolling in an Advantage Plan means signing up for private insurance plans, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), that take the place of Original Medicare. When it comes to Medicare provider options, selecting a Medicare Advantage Plan can be slightly more complex.
These plans operate within specific provider networks, which include:
- HMO Plans: These plans typically require you to select a primary care physician and get referrals for specialists. You’ll likely need to stay within the plan’s network to receive full coverage, except in emergencies, which could limit your ability to keep your current doctor if they’re out-of-network.
- PPO Plans: These plans offer more flexibility, allowing you to see an out-of-network doctor at a higher cost. If your current doctor isn’t in the PPO network, you can still visit them, but you’ll pay more out-of-pocket.
Before selecting a Medicare Advantage plan, check its provider directory to see if your doctor is included. If maintaining your current doctor is a priority, choose a plan that lists them as an in-network provider.
Remember that each year, insurers will renegotiate their contracts with Medicare providers, so your doctor’s participation in the plan can change annually.
What Do I Do If My Doctor Doesn’t Accept Medicare?
If your doctor doesn’t accept Medicare, you still have options to maintain access to care. Here’s what you can do:
- Ask About Payment Options: Some doctors who opt out of Medicare still see Medicare patients on a private-pay basis. You may need to pay out-of-pocket and cannot use Medicare benefits for these services.
- Consider a Medigap Plan: If your doctor is a non-participating provider, Medigap may cover any excess cost (up to 15% above Medicare’s approved amount). This could make it more affordable to continue seeing your current doctor.
- Find a Medicare-Participating Provider: Find a doctor in your area who accepts Medicare. While transitioning to a new provider can be both challenging and frustrating, it may be necessary to stay within your budget.
- Switch to a Medicare Advantage Plan: Some Medicare Advantage plans have broader provider networks that may include your current healthcare provider.
- Talk to Your Doctor: Communicate any concerns with your current doctor. They may have a solution that works for both of you.
Healthcare decisions are deeply personal and can have a profound impact on your life. They can affect your future and even make things impossible to change. That’s why it’s so important to think carefully about your health insurance and Medicare choices. If you want the best health results possible, you need to make sure that your trusted doctors are involved.
The end goal is to find a Medicare plan that lets you keep getting covered services from your recognized doctors that are covered by Medicare. By ensuring proper reimbursement for services, you can make sure you have the best health results possible by carefully considering your plan choices and making sure your doctors are covered. Remember, healthcare agreement is significant, and having the right doctors in your corner can make all the difference.
FAQs
Can I Keep My Doctor When I Switch to Medicare?
If your doctor accepts Medicare, you can keep them as your Medicare physician. With Original Medicare, you can visit any doctor who participates. For Medicare Advantage plans, you’ll need to confirm that your doctor is in-network.
Do All Healthcare Providers Accept Medicare?
No. While most do, some may be non-participating providers or may even opt out entirely. It’s always best to confirm with your healthcare provider before receiving care.
What Happens If My Doctor Doesn’t Accept Medicare?
In this case, you’ll need to explore options like private payment agreements, Medigap plans, or finding a new doctor who accepts Medicare coverage. You can also switch to a Medicare Advantage plan that includes your doctor in its network.
Do All Doctors Accept Medicare Advantage Plans?
No. These plans have specific networks, so it’s important to verify that your doctor is included before choosing a Medicare plan.
Do All Doctors Accept Medicare Supplemental Plans?
No. Doctors who opt out of Medicare will not accept Supplemental plans and may require you to pay at the time of service.