You do not have to switch providers if your doctor no longer accepts Medicare. However, you may see an increase in costs associated with using a doctor who does not accept Medicare assignments.
Do All Doctors Accept Medicare?
No, not all doctors accept Medicare. To accept Medicare, the doctor is required to “accept assignment.” By accepting assignments, doctors and their staff have two administrative requirements:
- They must accept Medicare’s payment schedule for services.
- They will submit claims on your behalf, and will only charge you the coinsurance, copays, and deductibles. They cannot charge you any additional amounts for a claim.
In return, when accepting assignments, doctors are paid directly from Medicare. You also generally pay less when you use doctors and other service providers when they accept Medicare assignments.
What Happens if Your Doctor Stops Accepting Medicare Insurance?
If your doctor stops accepting Medicare, you will be responsible for more of the fees associated with treatment upfront.
While most doctors do accept Medicare, common reasons they do not include:
- Decreased payments vs. non-Medicare health insurance: Medicare’s fee schedule pays out around 80% of traditional health insurance. Many doctors have not seen the Medicare fee schedule keep up with the rising costs of running a medical practice.
- Increased reporting and record-keeping requirements: Medicare has increased the reporting and record-keeping requirements for its beneficiaries to pay out claims. This coupled with payments that are severely reduced means many doctors do not see a profit from treating Medicare beneficiaries.
Option 1: You can stay with your doctor
Many people on Medicare have been seeing their doctor for years and don’t want to switch. When your doctor doesn’t accept Medicare, they can become one of two types of providers:
- Non-Medicare doctor: These doctors no longer accept Medicare at all. You will become responsible for all costs associated with seeing this provider and they are not required to accept the Medicare fee schedule.
- Non-participating doctor: These doctors do not completely separate from the Medicare insurance system. Instead, they decide on a case-by-case basis whether to accept an assignment or not. If they do not accept assignments, the maximum that they can charge you above the Medicare-approved fee schedule is 15%. These are known as excess charges.
Since you’ll be responsible for all costs associated with your healthcare with a non-Medicare doctor, you may be able to request a discount for paying the “cash price.” Due to the lowered reporting requirements, the costs associated with running a medical practice may be less. This could allow your provider to offer you a discount for all cash payments. It never hurts to ask if you’re in this situation.
Opt-out doctors are required to give you a breakdown of their costs upfront. Furthermore, you’re required to sign a contract saying you agree to the opt-out agreement.
Option 2: You can find a new Medicare provider
Depending on the type of Medicare coverage you have, there are two ways to find a provider that accepts your plan:
- Original Medicare: Under Original Medicare Parts A and B, you can use the Provider Compare tool. This tool allows you to search for providers using the following criteria:
- Location and ZIP code
- Area of practice (for example, cardiology)
- Gender
- Hospital affiliation
- Your doctor’s last name
- Medicare Advantage Plans (Part C): Medicare Advantage Plans are insurance plans that offer the same services as Original Medicare but may have different providers available to you. To search for a new provider under Medicare Advantage, you’ll need to check with the plan’s participating providers.
Option 3: You can visit an urgent care center
If you want to keep your current doctor, but don’t want to pay the higher costs of going to the doctor for everything, you can use an urgent care center for small, nonemergency, issues and then use your preferred doctor for illness management. Most urgent care centers accept Medicare assignments.
Will Switching Your Type of Medicare Plan Make a Difference if Your Doctor Doesn't Accept Medicare?
In an “opt-out private contract,” Medicare cannot pay any of the associated costs. They also cannot bill Medicare Advantage Plans for your services.
However, if you are using a Medicare Supplement Plan (Medigap), you will not pay anything for the services. You are responsible for contacting the Medigap company prior to receiving services.
How Often Can You Switch Medicare Providers?
With Medicare Supplement Plans and Original Medicare, you can switch providers pretty easily and with limited restrictions.
With Medicare Advantage Plans, it’s important to check with your insurance provider’s rules.
Learn More From Our Sources
- Medicare | How Original Medicare Works | Last accessed April 2024
- Medicare | How to Get Prescription Drug Coverage | Last accessed April 2024
- Medicare | Medicare Advantage Plans | Last accessed April 2024
- Medicare | What’s Medicare Supplement Insurance (Medigap)? | Last accessed April 2024