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Does Your Doctor Accept Medicare?

Having health insurance is like a promise – a promise that if you get sick or injured, you’ll have access to the doctor, hospital, and care that you need.

It’s the same promise that’s expected to be kept when transitioning from traditional healthcare to Medicare. But switching coverage can lead to wake-up calls, like whether or not your doctor accepts Medicare.

How Does This Apply to You?

First, let’s take a step back and find out if this is something you should be thinking about. There are two types of people who are covered by Medicare: those who have “original” (Part A and Part B) Medicare, or those who participate in a Medicare Advantage plan. If you’re in a Medicare Advantage plan, your private insurance company determines which hospitals and doctors will be covered and will only pay for services provided through their network.

But if you’re covered by Original Medicare, you need to know whether or not your doctor has done the following:

  • Chosen to participate in Medicare (or accepted “Medicare assignment”)
  • Elected not to participate in Medicare but did not fully opt-out
  • Completely opted out of Medicare

It sounds confusing, but each of the above scenarios can play out differently and it’s important to understand how this might impact you as a Medicare recipient (and your costs). So, we’ve made it a little easier to comprehend in the chart below.

Your Guide to Doctor Coverage Under Original Medicare

 

What the Doctor Can Charge

What You’ll Pay

How the Billing Works

Doctors Who Participate

The doctor can charge the amount allowed by the Medicare fee schedule* .

You will pay the Medicare deductible first, followed by coinsurance that is normally 20% of the Medicare fee schedule.

The doctor submits the bill to Medicare and will wait for Medicare to pay its share before asking you to pay your share.

Doctors Who Do Not Participate

The doctor can charge the amount allowed by the Medicare fee schedule* plus up to 15% above it (known as excess charges).

You will pay the Medicare deductible first, followed by coinsurance that is normally 20% of the Medicare fee schedule, plus excess charges if there are any.

If the doctor charges above the Medicare fee schedule, you will be billed for the total amount directly at the time of service.

Medicare will reimburse you for its portion of the covered charges.

Doctors Who Opted Out

The doctor can charge whatever fee they want to charge.

You will pay the full amount of the bill – Medicare does not pay anything.

You will be billed for the total amount directly at the time of service.

* A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.

At this point, you might be wondering how to learn about your own doctor’s participation in Medicare. The simplest way to find out? Give them a call.

You can also use the Physician Compare feature available on Medicare.gov. By entering your location and doctor’s last name into the search, you’ll be able to see whether or not they are participating.

If you want to learn more about your Medicare options in general, explore our Summary of Medicare, where you’ll become even more of an expert.