If you have health insurance through Medicare, whether or not your doctor accepts Medicare can make a big difference when it comes to your medical bills. Learn more about the specifics of why you should choose a participating provider—and what to expect if you choose not to—by reading on.
Before we get into the benefits of choosing a doctor who accepts Medicare (and the pitfalls of using a provider who doesn’t), let’s do a quick review of the three relationships healthcare providers can have with Medicare. Some doctors are participating—or enrolled—some are nonparticipating, and others have opted out of Medicare provider enrollment.
Medicare-Enrolled Providers will only charge the Medicare-approved amount for covered services and often cost less out of pocket than services from doctors who don’t accept Medicare.
Non-Participating Providers have no obligation to accept the Medicare-approved amount. However, they can choose to do so for any service. These doctors can charge more for their services than enrolled providers, adding up to 15% of the Medicare-approved amount.
Opt-Out Providers will bill you out of pocket in any amount for services in full; the charge limit does not apply. They require a private contract between patient and provider agreeing that neither will receive reimbursement from Medicare for services provided.
Benefits of Choosing a Doctor Who Accepts Medicare
- When you use a doctor who accepts Medicare, you’ll know exactly what to expect when you pay the bill. An enrolled provider won’t charge more than the Medicare-approved amount for covered services.
- You may pay less out of pocket with an enrolled doctor than with a nonparticipating or opt-out provider. That’s because you’re only responsible for your deductible and copayments for covered services.
- Most of the time, providers who accept Medicare will wait for Medicare to make payment on a claim before collecting your portion of the bill.
- You won’t need to worry about submitting claims to Medicare—your doctor will handle this for you at no charge.
Pitfalls of Selecting a Doctor Who Doesn’t Accept Medicare
- If your doctor is non-participating, you’ll usually need to pay out of pocket for all charges. Anything Medicare covers will be reimbursed to you. Opt-out providers will charge you in full for all services, and Medicare will not contribute toward these bills.
- You may be on your own when it comes to submitting claims to Medicare. To do so, you’ll use Form CMS-1490S.
- If you use a Medicare Supplement plan, your benefits won’t cover any services when your provider has opted out of Medicare.
- When you see a non-participating provider, you may have to pay the “limiting charge” in addition to your copay. The limiting charge can add up to 15% of the Medicare-approved amount to your bill. If your provider has opted out of Medicare, the limiting charge does not apply, and your provider can bill any amount he or she chooses.
Of course, Medicare provider enrollment is just one of the things you’ll need to consider when you choose a doctor. The good news is that it shouldn’t be too hard to find a participating doctor. Only about 4% of American doctors don’t accept Medicare. And if you’re a Medicare beneficiary, as you can see, provider enrollment can make a huge difference, primarily for your pocketbook.