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If you’ve been seeing the same doctor for years, it’s understandable that you would want to continue seeing them when you join Medicare.
This article will explain how to find a doctor who accepts Medicare, why it’s important, and where to find help if you have any questions.
New to Medicare? Here’s What You Need to Know
The federal Medicare program is health insurance for people 65 or older, certain people under 65 with disabilities, and people of any age with End-Stage Renal Disease (ESRD).
To help seniors cover the cost of medical services, Medicare is made up of different parts.
Part A (inpatient care) covers the care and treatment of patients in hospitals and other medical facilities. For example, hospice care and skilled nursing facility care.
Part B (outpatient care) includes coverage for outpatient care and services. This includes bills for specialist consultations, vaccines, and durable medical equipment such as wheelchairs and walkers.
Part D covers the cost of prescription drugs. Instead of being run by the government, you can buy this plan from a private insurance company.
If you’d like to learn more, read our 2022 guide to Medicare. This is where we outline all of the coverage options, Medicare benefits, and potential costs you should be aware of.
Do All Doctors Have to Accept Medicare?
Research shows that 97% of doctors and medical practitioners accept Medicare assignment.
This means that the healthcare providers agree (and are required by the federal government) to accept Medicare-approved amounts as full payment for medical services.
The doctor will charge Medicare 80% of the bill and you will have to pay the remaining 20%.
These are medical providers that can choose whether or not to take Medicare assignment for healthcare services.
What Could This Mean for Me?
If you visit a non-participating doctor, you will either have to cover the full medical bill or pay more than the Medicare-approved amount.
Some non-participating doctors can charge 15% more than the cost of the medical service you receive. This is known as a Medicare excess charge.
You would then have to cover 35% of the medical bill, instead of just 20%.
There are also doctors and medical practitioners who have chosen not to accept Medicare at all.
This means that Medicare will not pay for any medical services you get from an opt-out doctor unless it’s an emergency.
If you still want to see an opt-out doctor, you and the practitioner will have to agree to payment terms through a private contract.
The good news is that less than 1% of doctors have chosen to opt-out of Medicare, so the chances of you seeing one of these providers is unlikely.
The Bottom Line
If you visit a non-participating or opt-out doctor, you can expect your medical bill to be more expensive.
This is because you might have to pay the full medical bill upfront or pay 15% more than the Medicare-approved amount for the treatment you received.
If you see an opt-out provider, none of your medical expenses will be covered by Medicare (unless it’s an emergency) and you will have to pay for these yourself.
For these reasons, it’s important that you find doctors who will accept your Medicare plans.
Here are a few reasons why:
There will be fewer out-of-pocket expenses.
The doctor’s office will bill Medicare on your behalf and you cannot be charged before this happens.
You will only have to pay your deductible and coinsurance.
Terms You Need to Know:
Deductible: This refers to the set amount you pay for health care services before your health insurance kicks in. For example, if you have a $500 deductible you have to pay or reach $500 before your insurance kicks in.
Coinsurance: The percentage of costs you pay after your deductible has been met.
Copayment: A set rate you must pay for doctor visits, hospital stays and prescriptions.
Out-of-pocket costs: This term refers to expenses that are not covered by Medicare and that you must pay for yourself. For example, a fee for a visit to the physiotherapist.
How Do I Find a Doctor Who Accepts Medicare Assignment?
If you are a member of Original Medicare Parts A and B, you can use the Physician Compare tool on the Medicare.gov website to find a doctor who accepts Medicare assignment.
All you need to do is enter your ZIP code, city or state, and the medical specialty you are looking for.
You will then get a list of Medicare doctors or practices that accept assignment, as well as maps and directions so that you can find them.
By using this tool, you can also find information on:
An estimation of doctor’s costs for Medicare patients in your area.
Dialysis facilities and hospitals nearby.
Contact information for local inpatient rehabilitation centers.
Medicare Supplement Insurance Plans
Many seniors buy health insurance coverage called Medicare Supplement Insurance Plans (also known as Medigap) from licensed insurance agents.
These plans are designed to help pay for the remaining out-of-pocket costs that Medicare Parts A and B don’t cover. To learn more about affordable Medicare Plans, take a look at this article.
If you visit a Medicare doctor who accepts assignment, your Supplement Plan will pay for the remainder of the costs after Medicare has covered its portion.
Doctors who accept Medicare will automatically accept Supplement Insurance.
What If I Have Medicare Part C (Medicare Advantage Plan)?
Instead of receiving medical benefits through Medicare, some seniors choose Medicare Part C.
These plans are also available through private insurance companies and cover Parts A and B, as well as Part D for prescription drugs.
If you’d like to find out more about Medicare Advantage Plans, take a look at this article.
If you have a Medicare Part C, you will need to choose a primary care physician that participates in the plan’s network.
What does “network” refer to?
This means that the doctor or hospital has been approved and contracted by Medicare to provide medical care to its members.
The benefit of using a primary care doctor or hospital in Medicare’s provider network is that the cost of medical services will be lower.
This is because they will charge you the Medicare-approved rate for treatment.
The best way to find a doctor within your network is to contact the insurance company you bought your Medicare Advantage Plan from.
They will be able to give you a list of primary care physicians in your network who accept Medicare assignment.
What about Medicare Part D (Prescription Drug Benefit)?
This is insurance for seniors who need help covering the costs of self-administered prescription drugs (for example, antibiotics or blood pressure medication).
To learn more about where Medicare Part D fits in, how to enroll, what it costs, and more, be sure to read this article.
As of 2019, Medicare Part D will only cover the cost of prescription drugs from primary care doctors who are in Medicare’s network.
Once you have a list of primary care doctors who accept Medicare coverage, you can ask them to recommend pharmacies in your provider network that accept Medicare Part D.
By filling your prescriptions from pharmacies in your network, you can avoid paying higher out-of-pocket costs for your medication.
Where Do I Find More Information about Doctors Who Accept Medicare Payments?
For many seniors, it’s important to keep medical costs as low as possible. This is why you need to find a doctor that accepts Medicare payments.
For new Medicare beneficiaries, we know that this can get confusing and overwhelming very quickly.
If you need help finding a doctor who accepts Medicare coverage or have any questions about health insurance, contact one of our friendly consultants today.