Is It Possible for My Provider to Stop Accepting Medicare Payments?
The simple answer is yes, your medical provider can stop accepting Medicare payments, called assignment. Assignment means the provider agrees to accept the Medicare-approved amount as payment-in-full for covered services. Doctors and other medical providers are not required to accept patients covered by the Medicare program.
If your medical provider stops accepting Medicare assignment, or leaves your Medicare health plan network, you need to understand how it might affect your medical costs.
What kinds of Medicare providers don’t always accept Medicare payments?
Non-participating Medicare providers. These physicians and other medical providers might accept Medicare assignment in some cases, but they haven’t agreed to accept Medicare’s approved amount for every service.
If your medical provider falls in this category, he or she is a non-participating Medicare provider. By federal law, non-participating Medicare providers can bill patients no more than 15% above the Medicare-approved amount for certain Medicare-covered services. This is known as a limiting charge. The limiting charge does not apply to durable medical equipment or most medical supplies.
As a patient of a non-participating Medicare provider, you will be responsible for your 20% coinsurance (after you meet your annual deductible) plus the limiting charge cost. You may have to pay the entire bill at time of service and be reimbursed for the amount Medicare pays later.
Medicare Advantage providers. Perhaps you are enrolled in a Medicare Advantage plan that has a provider network. Either the Medicare Advantage plan or the provider may terminate their contract. They should provide you notice in advance of the contract termination.
In this case, the Medicare Advantage plan may assist you in finding another participating medical provider who provides the same kind of care. If you are enrolled in a Medicare Advantage Health Maintenance Organization (HMO) and you continue to see a medical provider who doesn’t participate in the plan, you will typically pay the full bill for non-emergency services.
If you are enrolled in a Medicare Advantage Preferred Provider Organization (PPO), you will usually pay a greater portion of the bill for non-emergency services from a medical provider who doesn’t participate in the plan.
Medicare opt-out medical providers. These are doctors and other medical providers who have decided not to provide services to anyone through Medicare.
If your medical provider falls in this category, he or she cannot bill Medicare nor receive payment from Medicare. You can still see this provider, but he or she must enter into a private written contract with you (unless you need emergency or urgent care). You are under no obligation to enter into a private contract with a medical provider who opts out of Medicare.
However, if you decide to receive care from a medical provider who opts-out of Medicare, you generally must pay the bills in full. Medicare generally will not pay for their services, even if these services would otherwise be covered by Medicare.
What steps you can take if your medical provider stops accepting Medicare (or leaves your plan)?
- Talk to your doctor or medical provider. Confirm whether your medical provider has opted out of Medicare. If you decide to stay with this provider anyway, remember (and remind your medical provider), you may have to pay the entire bill out-of-pocket even though you have Medicare coverage.
- If your doctor is a non-participating Medicare provider and you want to continue as his or her patient, you might want to consider purchasing a Medicare Supplement plan to work alongside your Medicare Part A and Part B coverage. Medicare Supplement Plans F and G may cover for Part B excess charges –that is, the difference between the Medicare-allowed amount for a service and the provider’s fee, up to 15% over the Medicare allowed amount. Please note that if you qualify for Medicare after January 1, 2020, you won’t be able to buy Plan F.
- Ask for a referral to a medical provider who accepts Medicare. If your doctor is part of a group practice, you might be able to switch to another medical provider in the same practice who accepts Medicare assignment.
- Compare plans using eHealth’s plan finder tool. You can enter a medical provider’s name and see what Medicare Advantage plan includes that provider in its network. Enter your zip code on this page to get started.
- Consult your plan’s Customer Service staff and/or provider directory to find another participating provider if you are enrolled in a Medicare Advantage plan.
- Use one of the annual enrollment periods to switch to another Medicare Advantage plan or to switch to Original Medicare if your medical provider accepts Medicare assignment. Here are two such periods:
- The Annual Election Period (October 15 – December 7)
- The Medicare Advantage Open Enrollment Period (January 1 – March 31)
You can match a medical provider to a Medicare Advantage plan, and compare plans where you live, right away. Type your zip code in the box on this page to begin, and click Add Your Doctors.