Not all doctors accept Medicare for the patients they see. This can leave you with higher out-of-pocket costs than you anticipated—and a tough decision if you really like that doctor. Fortunately, you have some options.
- If you choose a doctor who accepts Medicare, you won't be charged more than the Medicare-approved amount for covered services.
- A doctor can be a Medicare-enrolled provider, a non-participating provider, or an opt-out provider.
- Your doctor's Medicare status determines how much Medicare covers and your options for finding lower costs.
You’ve been going to the same doctor for 30 years, and they know you inside and out. Literally. Intimately familiar with your medical history, your beloved physician also has a wonderful bedside manner, a beautiful office, and friendly, efficient staff.
So what happens when you sign up for Medicare only to learn your all-time favorite doctor doesn’t accept it? It turns out this is an increasingly common occurrence. But there are ways to deal with it. This article outlines the basics of the program and some options to explore when your doctor doesn't accept Medicare.
What Is Medicare?
Medicare is a federal government-sponsored program. It provides medical insurance for American citizens age 65 and over. President Lyndon B. Johnson signed Medicare into law on July 30, 1965. By 1966, 19 million citizens were enrolled in the program.
Now, more than 50 years later, that number has mushroomed to more than 57 million—more than 18% of the U.S. population. As more baby boomers reach age 65, enrollment is expected to hit 64 million in 2020 and 81 million in 2030. It’s no wonder Medicare benefit payments totaled an estimated $731 billion in 2018.
If your long-time physician accepts assignment, this means they agree to accept Medicare-approved amounts for medical services. Lucky for you. All you’ll likely have to pay is the annual Medicare Part B deductible—$198 for 2020. As a Medicare patient, this is the ideal and most affordable scenario.
Doctors Say No to Medicare
Thanks to the federal program’s low reimbursement rates, stringent rules, and grueling paperwork process, many doctors are refusing to accept Medicare’s payment for services. Case in point: In 2000, nearly 80% of the Texas Medical Association’s doctors were taking new Medicare patients. By 2012, that number dropped to less than 60%.
Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that in the past several years, Medicare reimbursements haven't kept pace with inflation—especially the costs of running a medical practice. At the same time, the rules and regulations keep getting more onerous, as do penalties for not complying with them.
Here are your options if your doctor doesn't accept assignment.
1. Stay Put and Pay the Difference
If your doctor is what’s called a nonparticipating provider, it means he or she hasn’t signed an agreement to accept assignment for all Medicare-covered services but can still choose to accept assignment for individual patients. In other words, your doctor may take Medicare patients, but doesn’t agree to the program’s reimbursement rates. These nonparticipating providers can charge up to 15% over the official Medicare reimbursement amount.
If you choose to stick with your nonparticipating doctor, you’ll have to pay the difference between the fees and the Medicare reimbursement. Plus, you may have to cough up the entire amount of the bill during your office visit. Then, if you want to get paid back, either your doctor will submit a claim to Medicare or you may have to submit it yourself using Form CMS-1490S.
So, let’s say your doctor’s bill comes out to $300, and Medicare pays $250. This means you’ll have to pay the $50 difference, plus any copay, out of pocket. Obviously, this can add up quickly over time. However, you may be able to cover these extra expenses through a Medigap insurance policy. This coverage is also called Medigap Supplement Insurance. Provided by private insurers, it is designed to cover expenses not covered by Medicare.
2. Request a Discount
If your doctor is what’s called an opt-out provider, he or she may still be willing to see Medicare patients, but expects to be paid his or her full fee—not the much smaller Medicare reimbursement amount. These docs accept absolutely no Medicare reimbursement, and Medicare doesn't pay for any portion of the bills you receive from them. That means you are responsible for paying the full bill out of pocket.
Opt-out physicians are required to reveal the cost of all their services to you upfront. These doctors will also have you sign a private contract saying you agree to the opt-out method.
Of course, you can always try to negotiate a discount. It's not uncommon for physicians to lower their rates for established patients. As a courtesy, they may also offer extended payment plans if you're in need of a series of expensive treatments or procedures.
3. Visit an Urgent Care Center
Urgent care centers have become a popular place for people to go for their health care needs. According to the American Association of Pediatrics, there are as many as 4,000 to 9,000 urgent care centers in the U.S. These centers may also operate as walk-in clinics. Many provide both emergency and non-emergency services including the treatment of non-life-threatening injuries and illnesses, as well as lab services.
Most urgent care centers and walk-in clinics accept Medicare. Many of these clinics serve as primary care practices for some patients. So, if you just need a flu shot or you've come down with a relatively minor illness, you may consider going to one of these clinics. Save the doctor visits for the big stuff.
4. Ask Your Doctor for a Referral
If you simply cannot afford to stick with your doctor, ask them to recommend the next best doctor in town who does accept Medicare. Your current doctor has probably already prepared for this eventuality and arranged to transfer Medicare patients to another physician's care.
5. Search via Medicare's Directory
There are still plenty of doctors who take Medicare. You can find them in Medicare’s Physician Compare directory, a comprehensive list of physicians and healthcare providers across the nation. Once you pinpoint a provider, call to make sure they’re still taking on new Medicare patients. After all, this can change on a dime.
Another approach is to check the best local hospitals and see if any physicians on their staff are taking Medicare patients. When you get names, research them online to learn about their backgrounds.
The CARES Act of 2020
On March 27, 2020, President Trump signed a $2 trillion coronavirus emergency stimulus package, called the CARES (Coronavirus Aid, Relief, and Economic Security) Act, into law. It expands Medicare's ability to cover treatment and services for those affected by COVID-19. The CARES Act also:
- Increases flexibility for Medicare to cover telehealth services.
- Authorizes Medicare certification for home health services by physician assistants, nurse practitioners, and certified nurse specialists.
- Increases Medicare payments for COVID-19-related hospital stays and durable medical equipment.
For Medicaid, the CARES Act clarifies that non-expansion states can use the Medicaid program to cover COVID-19-related services for uninsured adults who would have qualified for Medicaid if the state had chosen to expand. Other populations with limited Medicaid coverage are also eligible for coverage under this state option.
The Bottom Line
Thanks to plummeting reimbursement rates, ever-tightening rules, and cumbersome paperwork, many doctors are dropping Medicare. If you recently enrolled in Medicare, only to find that your long-standing doctor doesn’t accept it, you have a number of options.
Also, just because you are eligible for Medicare doesn't mean you have to enroll in all four parts. If you have other health insurance—say, you're still working and can remain covered by your employer's group plan—you may want to stick with that plan. Medicare Advantage Plan networks are another alternative to investigate—physicians in those HMO-like plans have agreed to accept the network's fees.
Whether you choose to stick with your cherished physician and pay the potentially exorbitant price or switch to a doctor who does accept Medicare, it’s important to carefully crunch the numbers before you make a final decision. Also, review your own medical situation and whether you need your current doctor—or someone with similar expertise—because of a specialized health issue.