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Why Does My Doctor No Longer Accept Medicare? What Happens If My Doctor Leaves My Medicare Advantage Plan Network?

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A doctor or provider may decide to “opt out” of Medicare for various reasons; for example, a practice may feel the need to reduce overhead costs or wish to keep the number of patients down in order to maintain a suitable level of care.

If your doctor opts out of Medicare, this means that he or she is no longer enrolled in the Medicare program and does not submit any claims to the federal program or Medicare health plans. The doctor becomes exempt from Medicare-approved spending limits, and you become responsible for paying the complete cost of your health care if you stay with that doctor.

Your costs are generally lowest if you get your services from a Medicare-participating doctor or provider. Participating providers agree to “accept assignment” for all Medicare-covered services, meaning that they will not charge you above the Medicare-approved amounts for a service. You’ll still be responsible for any cost sharing that may apply, such as copayments, coinsurance, or deductibles.

There may be other situations where your doctor remains in the Medicare program, but can choose on a case-by-case basis whether or not to accept Medicare assignment. This is known as a non-participating provider. If a doctor does not accept Medicare assignment for a given service, it means he or she does not accept the Medicare-approved cost amount and can charge you up to 15% more for their services. This is known as a “limiting charge.”

Original Medicare (Part A and Part B)

If you’re enrolled in Original Medicare and your doctor opts out of the Medicare program, you can find doctors who accept Medicare through Medicare.gov’s Physician Compare website. This site is a national database of physicians, specialists, and other health-care professionals who are enrolled in the Medicare program. The site includes both participating and non-participating providers, but you can choose to filter your search to only display doctors that accept assignment.

Using the site is hassle-free and easy. The Physician Compare tool lets you search for doctors and providers by:

  • Location and zip code
  • Area of practice (for example, cardiology)
  • Gender
  • Hospital affiliation
  • Your doctor’s last name

After entering in your search criteria, the Physician Compare page will display a list of doctors in your area that meet your requirements. Before settling on a doctor, you should first call to confirm that he or she accepts Medicare assignment and is taking new patients.

Medicare Advantage plans (Part C)

If you are enrolled in a Medicare Advantage plan (such as an HMO or PPO), your plan can make changes to its provider network anytime throughout the year. Your doctor and providers may also join or leave your plan’s network at any time. If your doctor leaves your Medicare Advantage plan’s provider network and you’d like to continue seeing him or her, you have a few options.

  • Switch plans during the Annual Election Period: If your doctor is part of another Medicare Advantage plan’s provider network, you can switch plans during the next Annual Election Period (October 15 to December 7).
  • Disenroll from your Medicare Advantage plan: If your doctor is no longer in the provider network for any Medicare Advantage plan (but is still accepting Medicare), you may decide to go back to Original Medicare in order to continue seeing him or her. You can use the Annual Election Period to disenroll from your Medicare Advantage plan and return to Original Medicare. Or you can also disenroll from your plan during the Medicare Advantage Disenrollment Period (January 1 to February 14); you can also use this disenrollment period to enroll in a stand-alone Medicare Prescription Drug plan.
  • Switch plans during a Special Election Period: In some situations, the Centers for Medicare & Medicaid Services (CMS) may decide that the change in provider network was significant enough to warrant a Special Election Period. Your Medicare Advantage plan will notify you if your situation qualifies, and you’ll then be able to use your Special Election Period to either enroll in another Medicare Advantage plan or return to Original Medicare.

There may be certain circumstances where your Medicare Advantage plan leaves the Medicare program entirely or makes changes in its contract with CMS that affect you. When this happens, you may be eligible for a Special Election Period (SEP) that lets you make changes to your coverage.

Times when you may be eligible for a Special Election Period may include, but are not limited to:

  • Your Medicare Advantage plan does not renew its plan contract or reduces its service area for the upcoming plan year.
  • Your Medicare Advantage plan substantially changes its contract with CMS.
  • Your Medicare Advantage plan violates its contract with CMS.
  • CMS terminates your Medicare Advantage plan’s contract as a result of misconduct or other problems.

During a Special Election Period, you can enroll in another Medicare Advantage plan or return to Original Medicare. The rules about what you can do may vary depending on the situation that prompted the Special Election Period in the first place.

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