What Medicare Doctors Are in My Provider Network?
“How do I find doctors near me who accept Medicare?” That’s what you might be asking, especially if you’re new to Medicare or changing your coverage. There’s no single Medicare provider network, but there are ways to make sure your doctor accepts Medicare.
If you enroll in a Medicare Advantage plan, it might have a provider network. If it does:
- You generally don’t have to worry whether your doctor accepts Medicare, as long as you use network doctors. Typically all doctors in a Medicare Advantage plan’s network are Medicare doctors or other Medicare providers.
- You may have to use Medicare doctors in your plan’s provider network. Many Medicare Advantage plans use provider networks to keep costs low for their members. If you go outside your plan network, you might pay more.
Some other types of Medicare plans might have provider networks with Medicare doctors. Medicare Advantage plans are the most likely to have provider networks.
Doctors near me who accept Medicare: what does that really mean?
When we say a provider is a “Medicare doctor,” or that the doctor “accepts Medicare,” here’s what that generally means.
A Medicare-approved doctor can agree to accept Medicare assignment. That means the doctor (or other provider) agrees to accept what Medicare pays for that service, and won’t charge you more than the standard Medicare deductible or coinsurance/copayment. The Medicare doctor also can’t charge you for sending a claim to Medicare.
How do I know if I have to use Medicare doctors in a provider network?
Most Medicare Advantage plans are either HMOs (health maintenance organizations) or PPOs (preferred provider organizations). If you have an HMO plan, you must use doctors in your plan network or the insurance company may refuse to pay. If you need emergency care, your plan will pay even if you get treated out of your network.
If you have a PPO plan, you generally pay less if you use Medicare doctors in your plan’s network. For example, you may pay a $15 copayment for doctor visits within the provider network, but pay 50% of allowable charges for care outside the network.
Medicare Advantage PPO plans charge differently for in-network and out-of-network care, so you should check your plan details for specific cost information.
How do I find doctors near me that accept Medicare?
If you are enrolled in a Medicare Advantage plan, your plan will provide a directory of Medicare doctors in its provider network, if applicable. If you aren’t sure, call your Medicare doctor’s office and ask whether your plan is accepted before you make an appointment.
If you have Original Medicare, you don’t need to use doctors in a plan network. You can see any doctor you choose. But you can typically save money if you find a Medicare doctor who accepts Medicare payment terms (assignment). You may want to ask the doctor before you make an appointment.
If a doctor doesn’t accept Medicare, you may have to pay up front for your visit and file a claim for Medicare reimbursement. In some cases, doctors who don’t accept Medicare payment terms can charge up to 15% more than Medicare doctors for the same service.
Do I have to change Medicare doctors if my doctor isn’t in my provider network?
It depends on the type of Medicare Advantage plan you choose. If you enroll in a Medicare Advantage HMO, you will have to choose a primary care doctor within your provider network. Your primary care doctor will coordinate all other specialist care you need with Medicare doctors in the provider network.
If you choose a Medicare Advantage PPO, you may be able to keep your doctor, even if he or she isn’t in your provider network. However, it may cost you more than if you choose from the Medicare doctors within your plan’s preferred provider network.
If you are shopping for Medicare Advantage plans, it’s a good idea to look over the doctors in each plan’s provider network. Your doctor may not participate with one plan, but she may be in another plan’s network. If you have a long-term relationship with your doctor and you want to continue seeing her, you may decide Original Medicare is your best option if your doctor isn’t in a Medicare Advantage provider network.
You should also keep in mind that your Medicare Advantage plan may require you to use network providers for diagnostic tests and prescription medications, for example. If you enroll in a Medicare Advantage plan, be sure to check which hospitals, pharmacies, and outpatient facilities are in your plan’s provider network. If you don’t, you may end up paying the entire bill out of your own pocket for out-of-network services.
Remember, Medicare Advantage plans may change their provider networks from time to time. It’s always a good idea to ask if your provider accepts your plan each time you make an appointment. That way, you won’t have any unpleasant surprises when you pay your bill.
To look for a Medicare Advantage plan in your area, enter your zip code on this page.