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Summary: If you doctor stops accepting Medicare payment called “assignment,” you can either pay for that doctor out-of-pocket or find other Medicare doctors.
Some Medicare beneficiaries have seen the same doctor for decades and hope to continue for many years into the future. Here’s what to do in the unfortunate circumstance when your Medicare doctors stops accepting Medicare payment.
According to the Centers for Medicare and Medicaid Services (CMS) most doctors will accept Medicare. This means that they will:
To become participating Medicare doctors, according to CMS, they must sign an agreement with Medicare. That means they need to follow the rules for any medical services they provide you with. This also applies to other medical providers, like nurse practitioners, nutritionists, and therapists.
In other words, Medicare doctors only ask you to pay coinsurance or copays and/or deductibles when you visit. They will send a claim to Medicare for their portion of the cost. They also can’t add an extra charge for agreeing to submit your claim for you.
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.
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 the charges from the non-Medicare doctor.
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.”
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:
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.
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.
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:
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.
To find a Medicare Advantage plan in your area, enter your zip code on this page.
eHealth's Medicare website is operated by eHealthInsurance Services, Inc., a licensed health insurance agency doing business as eHealth. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company. eHealth and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies.