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Q: Will all doctors accept my Medicare coverage?
A: The answer depends on what type of Medicare coverage you have, and whether you’re already a current patient.
People with Original Medicare have access to doctors across the United States. Although CMS (the Centers for Medicare and Medicaid Services) does not publicly track how many doctors accept Medicare patients, the Kaiser Family Foundation found that 93% of primary care providers surveyed accepted Medicare. However, only 72% of them were taking new Medicare patients. Some providers who don’t accept new Medicare patients will continue seeing existing patients who move from private coverage into Medicare.
What you pay will vary depending on whether your doctor is a Medicare participating provider, meaning they accept Medicare’s payment (plus Part B coinsurance) as payment in full. (Medicare participating providers are also referred to as providers that “accept assignment.”) KFF found that 96% of Original Medicare doctors were participating providers, while 4% did not participate. Non-participating providers can charge patients up to 115% of Medicare’s rates, minus the amount Medicare pays. Medigap Plans F and G can cover these additional amounts, which are known as excess charges. (Some states don’t allow excess charges.)
A small number of providers don’t bill Medicare at all. Just over 26,000 providers have “opted out” of Medicare as of March 2020, which means they can’t see Medicare beneficiaries without entering into a private contract where the patient agrees to pay full price. More specialists opt out of Medicare than other types of providers. (Although less than 1% of providers have opted-out, 40% of those doctors are psychiatrists.)
Original Medicare providers choose whether to “accept assignment,” meaning they consider Medicare’s approved rate (plus coinsurance) as full payment. Providers who accept assignment are also known as Medicare participating providers. Non-participating providers can charge patients 115% of the Medicare approved amount, less Medicare’s payment. Medigap Plans F and G cover these amounts, which are known as excess charges.
These terms are confusing and can impact what you’ll pay for care, so it’s a good idea to check with your provider about their Medicare status.
People with Original Medicare can purchase supplemental coverage through Medigap. Coverage varies across the 10 federally standardized plans, but they all cover some portion of Medicare beneficiaries’ Part B cost sharing as well as the cost of hospitalization under Part A. If you visit the doctor or are hospitalized, both your Medigap card and your Original Medicare card will be needed to process your bills. Even though Original Medicare often will automatically send claims to your Medigap insurer, your health care provider will need to see your Medigap card in case this doesn’t happen or there are other billing issues.
Most people with Medicare have multiple insurance cards. If you’re enrolled in Medicare Advantage, you’ll have both an Original Medicare card (which is red, white and blue) and a card from your Medicare Advantage insurer. You’ll use your Medicare Advantage card when you seek care, but hold on to both cards in case you switch back to Original Medicare. (Medicare’s hospice benefit is covered through Original Medicare even if you’re enrolled in a Medicare Advantage plan.)
While Original Medicare is known for offering expansive access to physicians, it is not always a guarantee of access to a specific physician. Some medical practices only take patients with Medicare Advantage plans, while others see patients who have Original Medicare.
Medicare Advantage plans must cover emergency room and urgent care at in-network rates even if you are treated out-of-network. Some plans cover routine out-of-network care, meaning you can see any Medicare provider for routine care. (These plans will have a separate out-of-pocket maximum for out-of-network services.)
All Advantage plans must include an adequate number of providers and hospitals in their networks. If you have to seek routine care from an out-of-network provider, your insurer may agree to cover it at in-network rates if an appropriate provider is unavailable in-network. Ask your health care provider if you’re unsure whether they’re in-network with your Advantage plan.
If you have a stand-alone Part D prescription drug plan, you’ll use the card from that Part D insurer at your pharmacy. Medicare Advantage enrollees with embedded prescription drug coverage can use their Medicare Advantage card to fill prescriptions. All Part D plans have pharmacy networks, and your co-pays will be different depending on if you use a preferred or non-preferred pharmacy. You can use the Medicare plan finder or call your Part D plan to see if you can pay less by filling your medications at a different pharmacy.
Part D insurers will only pay for medications from out-of-network pharmacies in an emergency. You will likely have to pay the difference between your insurer’s usual and customary rates and the out-of-network pharmacy’s charges.
You may have other insurance cards in addition to cards for Original Medicare (which everyone has), Medicare Advantage and Medigap. Insurers will usually send you a new card each year, although your Original Medicare card will not change. It’s a good idea to make sure your providers have up-to-date insurance information for you so there aren’t delays in billing for medical care.
Although it all adds up to a lot to carry, it’s probably best to keep your Original Medicare, Medicare Advantage, Medigap, and Part D cards with you at all times. Because there’s less of a chance you might spontaneously need other insurance cards – like a private dental plan or long-term care insurance policy – so you can probably store those in a safe place at home.
If you are struggling to choose Medicare coverage that includes your health care providers, free help is available from State Health Insurance Assistance Programs (SHIPs) in each state.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated 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.