Do Most Primary Care Doctors Accept Medicare?
Summary: Research showed that 93% of primary care doctors accept Medicare, but only 70% are accepting new patients.
A primary care doctor is the health care provider who handles most of your health issues and refers you to specialists when you need more specialized care. Your primary doctor can be a family practice physician, general practitioner, or focus on internal medicine. Some seniors choose a geriatrician, which is a doctor who specializes in treatment and prevention of diseases that affect older adults, as their primary care doctor.
If you’re enrolled in Medicare, finding a primary care doctor who accepts Medicare is important for managing your out-of-pocket health care costs and getting your medical bills paid. The good news is that the majority of physicians accept Medicare, according to the Kaiser Family Foundation.
What percentage of primary care doctors accept Medicare?
Overall, Kaiser Family Foundation (KFF) research showed that 93% of primary care doctors accept Medicare. That doesn’t tell the whole story, however, especially if you’re new to Medicare.
Breaking down the data further, only about 70% are currently accepting new Medicare patients, and an additional 21% accepts Medicare for their existing patients but aren’t taking new Medicare patients.
The number of family practice doctors who accept Medicare is almost equal to the percentage of those accepting private insurance. In other words, Medicare beneficiaries are not at a disadvantage compared to individuals with private insurance coverage.
If you have Medicaid, however, you may have more trouble finding a primary care doctor who accepts your insurance. Only 45% of primary care physicians accept new Medicaid patients according to KFF.
Do I need to choose a primary care doctor if I’m on Medicare?
If you enroll in Original Medicare (Part A and Part B), you aren’t required to formally select a primary care doctor. However, if you choose to get your Medicare benefits through a Medicare Advantage plan, you may need to choose a primary care physician.
Medicare Advantage HMO (Health Maintenance Organization) plans, which account for 64% of all Medicare Advantage plans according to the Kaiser Family Foundation, require enrollees to select a primary care doctor to oversee their health care.
Medicare Advantage HMOs and preferred provider organizations (PPOs) use physician networks to help keep costs down. If you see a network provider, you know your plan is accepted and you’ll pay the lowest amount out-of-pocket for your care.
What happens if I see a primary care doctor who doesn’t accept Medicare?
If you have a primary care doctor who is a Medicare non-participating provider, you can still see him or her for your health care. If a doctor doesn’t participate with Medicare, it simply means he will see Medicare patients, but won’t accept Medicare reimbursement as payment in full.
That doesn’t mean you have to pay the full amount charged to people with private insurance, however. Federal law limits the amount a non-participating doctor can charge a Medicare patient to just 15% over Medicare reimbursement rates. In other words, if an office visit normally costs $100, but the Medicare reimbursement rate is $35, you can only be charged $40.25 for the visit (15% of $35 = $5.25).
If you’ve met your Part B deductible for the year, you would pay 20% of the $35 reimbursement rate ($7.00) plus the $5.25 “excess charge” for a total of $12.25. Some states limit excess charges even more; New York, for example, allows doctors to charge just 5% above Medicare reimbursement rates.
If your primary care doctor is an “opt-out” provider, however, you’re likely on the hook for the full cost of your care. An opt-out provider has signed an agreement with Medicare to be excluded from the program. An opt-out primary care doctor must disclose this to you before you get care, and reveal the full cost of services. He must also provide you with a private contract indicating you understand you are responsible for payment in full.
Opt-out providers don’t bill Medicare, and Medicare doesn’t pay anything, even the standard reimbursement rate, except in the case of emergency care.
Why don’t all primary care doctors accept Medicare?
Doctors have different reasons for not participating with Medicare, but there are two issues most often mentioned by those who don’t.
First, Medicare reimbursement schedules are generally lower than those of private insurance companies. The data from the Kaiser research shows that older, more established doctors are less likely to accept Medicare than younger doctors. This may be because younger doctors trying to build a practice are willing to accept Medicare’s lower payments.
Medicare’s administrative burden is the second most common reason primary care doctors choose not to participate with Medicare. Medicare is a government program subject to stringent federal and state oversight. Medicare typically requires more paperwork than private insurance, and billing and reimbursement rules and procedures are more complex. The extra administrative costs combined with lower reimbursement rates may deter physicians from participating with Medicare.
To find a Medicare Advantage plan in your area, enter your ZIP code on this page.
Out-of-network/non- contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call the plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.