Q: Will all doctors accept my Medicare card? Which Medicare card should I use when I visit the doctor?
A: The answer depends on what type of Medicare coverage you have.
If you have Original Medicare
People with Original Medicare, also known as fee-for-service Medicare, can see almost any doctor in the United States. Most U.S. doctors (96 percent) are registered to bill Original Medicare for your healthcare. (This type of coverage is also known as fee-for-service Medicare, because providers are usually reimbursed for office visits on a per-visit or per-procedure basis.)
Of the more almost 1 million doctors in the United States, the federal government reported in 2012 that less than 10,000 had entirely separated themselves from the Medicare program, something known formally as “opting out” of Medicare. Doctors who choose to opt out of Medicare must file paperwork (which gets renewed every two years) with the federal government.
These doctors agree to not treat Medicare beneficiaries – unless the beneficiary enters into a private contract where they agree to pay the entire cost of care. These costs are not limited to what Medicare would allow for the same treatment.
Although the number of providers who don’t treat most Medicare patients is small, more specialists (especially dermatologists and gynecologists) choose to see patients on a private-pay basis because they feel that Medicare’s reimbursement is less than the cost to them to provide health care to those Medicare patients.
If your provider claims to accept Medicare members, you should check whether the provider accepts Medicare’s payment (plus any share of the cost you owe) as payment in full for your health care. This practice is known as “accepting assignment,” and is an important distinction between Medicare providers. (Another term for accepting assignment is being a Medicare “participating provider.”)
Because the terms are confusing – and doctors themselves may not understand or be able to explain their exact status with Medicare and how it affects what you will owe at the doctor’s office – be sure to also speak with billing staff (who may be involved in the day-to-day billing details and have a clearer answer for you) with detailed questions.
If the provider doesn’t accept assignment, that means you could have to pay up to 15 percent more than the Medicare approved amount.
If you have a Medigap plan
Some Medigap supplemental plans pay an additional set of charges, known as “excess charges” in insurance lingo – so be sure to check with your doctor to see if he or she accepts assignment and with your Medigap insurer to see if your supplement plan covers charges above the Medicare approved amount.
If you have Medicare Advantage
If you choose to receive your Medicare coverage through a Medicare Advantage plan, rather than directly from the federal government, you will have a red, white and blue Medicare card and a private Medicare Advantage plan card (example to the right). It is important to know the difference between your Medicare card issued by the federal government and your other Medicare insurance cards.
Moreover, some physician practices prefer to accept patients who are insured with certain Medicare Advantage plans, which can provide higher reimbursement and may have an agreement to coordinate physician practices’ patients’ care – in different ways than are offered under Original Medicare.
Providers in Medicare Advantage plans are required by the federal government to always accept Medicare’s payment (or the Medicare plan’s payment) as the full obligation for their patients. As a result, members of a Medicare Advantage plan who see in-network providers are protected in some ways from excess costs other Medicare beneficiaries may incur.
By contrast, if you have a Medicare Advantage plan and see a Medicare provider who participates in Original Medicare, but not your particular MA plan, you could be hit with large medical bills you have to pay all by yourself. Medicare Advantage plans generally will cover provider services outside of their networks only if the service is related to urgently needed care or emergency care. With pre-approval, plans may agree to cover non-network providers at in-network rates if an appropriate provider isn’t available within the plan’s own provider network.
What about my Medicare prescription drug coverage?
Opt-out status applies to those Medicare beneficiaries who are enrolled in either a Medicare Advantage plan or fee-for-service Medicare. If you see a provider who has opted out of Medicare, you may still be able to fill his or her prescriptions under your Medicare Part D prescription drug coverage – if he or she is properly documented in Medicare and other federal government computer systems as a legitimate health care provider.
What about my other insurance cards?
In addition to a card for Original Medicare, Medicare Advantage, or Medigap – and sometimes a separate Part D plan – some people have additional coverage and cards:
- A Medicaid card – if you have Medicaid benefits in addition to Medicare
- A Medicaid managed care card – if you have managed Medicaid benefits
- A Medicaid managed long-term care insurance plan card
- A private long-term care insurance card – if you have private long-term care insurance
- A private dental or vision insurance card
Review the list of those doctors who do participate in the Medicare program on Medicare.gov. And if you are in doubt, also ask your provider’s office and health plan for clarification about which providers are part of Medicare’s network or your health plan’s network. If you have additional questions, you can reach out to a State Health Insurance Assistance Program (SHIP) – free Medicare counseling in your state – for more assistance.
The good news is that your Medicare coverage options are expansive – allowing flexibility to select plans that meet your needs. As a savvy consumer, your job is to ensure you maximize your engagement with your care and understand what card to use when. This will allow you to make the most of your Medicare benefits.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He managed a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals.
In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients on Medicare and Medicaid issues.
Contributions to healthinsurance.org and medicareresources.org represent only his own views.