Is My Doctor Covered by Medicare?
This article was updated on: 09/16/2018
You may have concerns about finding a Medicare-approved doctor so you can maximize coverage, get help filing claims, and reduce your out-of-pocket expenses. Medicare Part B (medical insurance) covers medically-necessary services or covered preventive tests you receive from your doctor in an office, hospital, or other setting.
According to Medcare.gov, a doctor can be a Doctor of Medicine (MD); a Doctor of Osteopathic Medicine (DO); or in specific cases, a dentist, podiatrist, chiropractor, or optometrist. Medicare may also cover treatment given by other health-care providers, such as physician assistants, nurse practitioners, physical and occupational therapists, and clinical psychologists. Though there are many Medicare-approved doctors, it’s a good idea to check, because the choice of one specific medical provider over another may impact your out-of-pocket costs.
How do Medicare-assigned or Medicare-participating doctors help you reduce costs?
Doctors or health-care providers who accept Medicare assignment agree to the Medicare-approved amount as payment in full for covered services. This means the provider charges a Medicare-approved amount for each covered service. These Medicare-assigned doctors also agree to submit claims for their patients, and they can’t charge for this service.
People who rely upon Medicare Part B to cover doctor visits can usually save time and money by choosing doctors who always accept Medicare assignment. These providers have signed an agreement to accept assignment for all Medicare-covered services; they are called “participating providers.”
To summarize, if your doctor, provider, or supplier accepts Medicare assignment, this means:
- They agree to charge you only the Medicare coinsurance amount and deductible.
- You may have lower out-of-pocket costs. In Original Medicare (Part A and B), you usually pay 20% of the Medicare-approved amount as coinsurance, after you’ve met the Part B deductible.
- They usually wait for Medicare to pay its share before asking for you to pay and will submit the bill directly to Medicare.
What if your doctor or other medical provider doesn’t always accept Medicare assignment?
Doctors who haven’t signed an agreement to accept assignment for all Medicare-covered services are called non-participating providers. Non-participating providers may choose to accept Medicare-assignment for some individual services but not all services.
If you choose to see a non-participating provider for a Medicare-covered service, here’s what you should know:
- You may have to pay the entire charge for the service up front.
- The doctor is supposed to submit a claim (a request for payment) to Medicare; however in some cases you might have to submit your own claim to Medicare to request payment.
- The doctor can charge you more than the Medicare-approved amount, but there is a limit (the “limiting charge”). They can only charge you up to 15% more than the Medicare-approved amount, and the limiting charge will only apply to specific Medicare-covered services.
It’s not uncommon to find specialists and clinics that charge more than the Medicare-approved amount. If you decide to visit a provider who charges more than Medicare allows, you are free to do that. You might pay more and might have to wait for reimbursement for covered amounts.
Medicare has a term for the amount that a doctor charges over the Medicare-approved amount, and that term is called excess charges. If you plan to only see Medicare-participating doctors, you may never have to worry about excess charges. If your doctor is a “non-participating” provider as mentioned above, you may want to consider purchasing a Medicare Supplement (Medigap) plan that pays for these excess charges. Medicare Supplement plans are offered by private insurance companies and can help you pay for some health-care costs Original Medicare doesn’t pay like copayments, coinsurance and deductibles. It is important to note that not every Medicare Supplement plan covers excess charges. Also, Medicare Supplement plans only pay for the out-of-pocket costs associated with Medicare-covered services – that is, services Medicare covers except for the out-of-pocket costs such as copayments and deductibles.
For example, these Medicare Supplement (Medigap) plans cover excess charges:
- Medigap Plan F or high-deductible Plan F (after you’ve paid the deductible for the high-deductible plan)
- Medigap Plan G
There are some doctors who’ve decided not to provide services to anyone through Medicare. Please note that if you decide to see a provider like this and sign a private contract with him or her, you’ll need to pay the full amount the provider charges, and Medicare generally won’t pay any amount for the medical services, even if it’s usually a Medicare-covered service.
What if I enroll in a Medicare Advantage plan and see a doctor?
If you decide to enroll in a Medicare Advantage plan with a network, excess charges typically won’t be charged if you visit in-network doctors. Medicare Advantage plans are an alternative way to receive Original Medicare (Parts A and B) benefits (except for hospice care, which Part A will still provide). Medicare Advantage plans are offered by private insurance companies that contract with Medicare. Please note that you’ll still need to pay your Part B premium, along with any premium the Medicare Advantage plan requires, and any copayments, coinsurance, and deductibles.
Medicare-approved doctors who contract with a Medicare Advantage plan (and belong to its designated network of providers) will agree to comply with the billing limits that the insurance company allows. If you choose an out-of-network provider or have a private-fee-for-service plan, you could have higher out-of-pocket costs. In these cases, the insurance company’s allowed amounts, and not Medicare’s, would apply.
There are several different types of Medicare Advantage plans, and they each may have their own rules about which doctors you can see (please check with your individual plan). Here are descriptions of some common types of Medicare Advantage plans:
- Health Maintenance Organization (HMO) plans: Generally, you must get care and services from doctors or other health-care providers who are within the plan’s network (except for emergency care, urgent care if you’re out of the area, and out-of-area dialysis). Some plans (such as an HMO with a point-of-service option) may allow you to receive care out-of-network, but usually at a higher cost.
- Preferred Provider Organization (PPO)* plans: In most cases, you can see any doctor or health-care provider, but if it’s not a doctor, specialist, or hospital that’s on the plan’s list of network providers, then it may cost more.
- Private Fee-for-Service (PFFS) plans: These plans define their own payment terms with providers, and how much you pay for services. In some cases, you can receive care from any doctor. If the plan you enroll in has a network, you can see any of the network providers, or choose to go out-of-network if the provider accepts the terms of the plan.
- Special Needs Plans (SNPs): Typically, you have to get your care from doctors within the plan’s network (except for emergency or urgent care).
How can I find a doctor who accepts Medicare assignment?
Medicare.gov has a Physician Compare tool that may help you find a doctor in your area.
As an eHealth licensed insurance agent, I can help you find a Medicare-approved doctor. We can also help with questions you may have about Medicare plan options. Please click on the links below to schedule an appointment to talk with us or have us email you personalized information. You may browse for Medicare plan options using the Compare Plans button on this page.
*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 the plan will cover an out-of-network service, we encourage you or your provider to ask the plan for a pre-service organization determination before you receive the service. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.