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What If My Medicare Doctor “Opts Out”?

Finding a doctor you like and trust can be a long process, so I understand that it can be frustrating when your doctor no longer accepts Medicare. If your doctor has “opted out” of Medicare, this means that he or she no longer accepts Medicare assignment (participating in a payment agreement with Medicare). If your doctor doesn’t accept Medicare assignment, you may have to pay a higher amount for that doctor’s services.

It’s important to understand how finding a doctor that accepts Medicare may affect your out-of-pocket costs. Learn what to do if your Medicare doctor leaves the program.

How using a participating or non-participating Medicare doctor affects your costs

It might help to start by explaining how using a participating Medicare doctor or provider may affect what you pay for Medicare-covered services.

If you’re enrolled in Original Medicare (Part A and Part B) and trying to find a doctor who accepts Medicare, you may have come across the phrases “participating” and “non-participating.” These terms have to do with how Medicare reimburses doctors and providers. When it comes to Original Medicare, the Medicare program has approved certain payment amounts for doctors, health-care professionals, and suppliers who provide covered services and equipment.

A participating Medicare doctor is contracted with Medicare to accept Medicare’s reimbursement rates as full payment (as mentioned above, this is also known as “accepting Medicare assignment”). If you visit a participating Medicare doctor, you won’t be charged more than the amount Medicare has approved for that health-care service, although you may still owe cost sharing (such as deductibles, copayments, and/or coinsurance).

On the other hand, a non-participating Medicare doctor or provider doesn’t have to accept assignment (although he or she may choose to do so for certain services). This means that you might have to pay the full cost for your health care up front. A non-participating Medicare doctor is also allowed to charge you up to 15% above the Medicare-approved amount for that service.

In other words, your costs will be lowest if you use a participating Medicare doctor because he or she won’t charge you above the amount that Medicare has approved for that service. If you do visit a non-participating Medicare doctor, check if he or she will accept Medicare assignment for that particular service.

Finding a participating Medicare doctor if you have Original Medicare, Part A and Part B

If you’re enrolled in Original Medicare and you are notified that your doctor has opted out, this means that your doctor is now a non-participating provider. If you’d like to keep seeing your doctor, make sure to ask him or her beforehand how this may affect your costs. Your doctor may choose to still accept Medicare assignment for certain services.

You may also decide to switch doctors. You can use Medicare.gov’s Physician Compare tool to find a different Medicare doctor who accepts assignment.

Medicare.gov’s Physician Compare tool has a variety of features to make it easier for you to find a participating Medicare doctor or health-care provider in your area:

  • You can enter your zip code, city, and state, or address to find Medicare doctors in your specific location.
  • You can enter your doctor’s last name or search for Medicare doctors by specialty or the health condition they treat. The tool makes it easy with a drop-down menu of suggested search terms. For example, if you enter “Heart,” the tool offers a list you can select from, such as Cardiovascular Disease (cardiology).
  • You can search for Medicare doctors by group practice.
  • You can choose to filter your search to only show either male or female Medicare doctors if you have a preference.
  • You can filter your search to only show participating Medicare doctors who accept Medicare assignment for all covered services. Or, you can choose to view all doctors and providers in the search results, regardless of how they may bill you.

When you find a Medicare doctor, you may want to call and confirm that she or he still accepts Medicare assignment, and new patients, before making an appointment. Remember, if the doctor doesn’t accept Medicare assignment, your costs could be higher.

Finding a doctor who accepts Medicare if you have Medicare Advantage (Part C) 

If you’re enrolled in Medicare Part C (Medicare Advantage), finding a Medicare doctor works differently. Medicare Advantage plans often contract with doctors, hospitals and other health-care providers. This is called a provider network. Medicare Advantage plans don’t follow the fee schedule set by the Original Medicare program; instead, each plan negotiates reimbursement rates with its contracted providers. In other words, your costs may vary with each Medicare Advantage plan, depending on the rates that the plan has set with its providers.

Depending on the type of plan you’re enrolled in, you may be required to get health-care services from Medicare doctors in your plan’s provider network in order to be covered. For example, Health Maintenance Organization (HMO) plans often won’t cover you if you use non-network providers unless it’s a medical emergency, whereas Preferred Provider Organization (PPO) plans* give you more flexibility to use non-network providers at a higher cost sharing. Some types of Medicare Advantage plans, such as Medicare Medical Savings Account (MSA) plans, don’t use provider networks. In this case, finding a doctor who accepts Medicare would work similarly to Original Medicare, and you’ll want to make sure you use a participating Medicare doctor who accepts assignment.

If you receive your Medicare benefits through a Medicare Advantage plan, there may be times when your doctor discontinues his or her contract with the Medicare Advantage plan, or the plan may choose to terminate its contract. Keep in mind that the provider network may change at any time. If this happens, you will receive notice from your Medicare Advantage plan. In some cases, if the changes to the provider network are significant enough, you may be eligible to change Medicare plans with a Special Election Period (SEP). You’ll be notified by your plan if you qualify for an SEP. Otherwise, you may have to wait until the Annual Election Period (AEP) from October 15 to December 7 to switch to a different plan that includes your doctor in its provider network.

*Out-of-network/non-contracted providers are under no obligation to treat Preferred Provider Organization (PPO) plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

https://www.ehealthinsurance.com/medicare/blog/medicare-tips/what-if-my-medicare-doctor-opts-out/

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