The good news is that most doctors take Medicare. Only 1% of non-pediatric physicians opted out of Medicare in 2020. That does not mean that every Medicare doctor is currently taking new patients or that they are in your plan’s network. Some Medicare doctors may even charge you more. Before you choose one, this is what you need to know.

Doctors on Original Medicare

If you want your pick of Medicare doctors, Original Medicare is the way to go. You can see any doctor in the nation who “opts in” for Medicare, meaning that they accept Medicare for payment. How much you pay depends on whether your Medicare doctor is a participating or non-participating provider.

PARTICIPATING:

Doctors who “participate” agree to charge no more than what is recommended on the Medicare fee schedule each year.

THE MATH: Medicare will pay 80% for their visits, leaving you to pay the remaining 20%, i.e., a $100 visit would cost you $20. That said, Medicare covers 100% of your Annual Wellness Visits. When preventive screening tests (i.e., bone scans, mammograms, colonoscopies, etc.) are ordered by one of these doctors, they are free to you too.

GOOD NEWS: As many as 97% of doctors are participating providers.

NON-PARTICIPATING:

Doctors who are “non-participating” take Medicare for payment but they do NOT agree to the fee schedule. They may believe their services are worth more. By not participating, they are allowed to charge you up to 15% more for their services. This is known as the limiting charge.

THE MATH: To make sure doctors do not take advantage of the situation, Medicare decreases the value of the service by 5%, i.e., a $100 service on the Medicare fee schedule would only be approved for $95. Medicare pays them 80% of the new approved amount = $76 (80% x $95), leaving you to pay $19 (20% x $95). The doctor can charge you up to 15% above the Medicare-approved amount, in this case $14.25 (15% x $95). In the end, you pay $33.25 ($19 + $14.25), $13.25 more than if you had a participating provider.

GOOD NEWS: Eight states do not allow extra charges: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.

PRO TIP: Medigap plans F and G cover these excess charges. If you sign up for one, you won’t have to worry about what kind of Medicare doctor you see.

Doctors on Medicare Advantage

Unlike Original Medicare, your choice of Medicare doctors narrows quite a bit when you go on a Medicare Advantage plan. That is because these plans are based on a local network of providers. If you see a doctor outside of that network, even if they take Medicare, you will have to pay more for their care. In the worst case scenario, your plan won’t pay for their services at all.

The participating and non-participating status of your Medicare doctor does not really apply here. That’s because Medicare Advantage plans set their own rates. You will usually pay more to see a specialist than a primary care physician.

GOOD NEWS: The No Surprises Act won’t allow you to be overcharged when you go to an out-of-network hospital during an emergency. It also protects you when you receive care at an in-network facility but a provider working there was out-of-network. In that case, you received care from that provider but you were not notified. Alternatively, you were notified but were not given in-network options.

Non-Physician Healthcare Providers

Not everyone will choose to see a physician. Your healthcare provider could also be a nurse practitioner (APRN) or a physician assistant (PA). They train fewer years than a physician, but they can all provide quality care. Like physicians, they sign contracts with Medicare to be participating or non-participating providers.

While a nurse practitioner or physician assistant can be your primary care provider, they are not allowed to certify that you are terminally ill if you need to go on hospice. You will need a physician member of their medical team to complete that paperwork for you.

GOOD NEWS: Your costs do not change based on what kind of provider you choose to see.

 

How Many Physicians Have Opted-Out of the Medicare Program? (2020). KFF. https://www.kff.org/medicare/issue-brief/how-many-physicians-have-opted-out-of-the-medicare-program/

MEDICARE PART B MEDICAL INSURANCE 2022 HIICAP NOTEBOOK 4-1. (2022). New York State Office for the Aging. https://aging.ny.gov/system/files/documents/2022/06/mod-4-medicare-part-b-medical-insurance-hiicap-notebook-2022.pdf

Pub 100-02 Medicare Benefit Policy Change Request. (2018). CMS.gov. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R246BP.pdf

U.S. Congress. (2020, December 28). H.R. 133 (ENR) – Consolidated Appropriations Act, 2021. Government Printing Office. https://www.govinfo.gov/app/details/BILLS-116hr133enr