Doctors with regard to Medicare fall into three buckets: participating, non-participating, and opt-out

Will All Doctors Accept My Medicare Plan?

Sadly, no. Doctors with regard to Medicare fall into three buckets: participating, non-participating, and opt-out. Participating doctors have agreed to accept Medicare assignment. This means that they will file the Medicare claim for you and accept whatever Medicare determines is a fair payment as payment in full (you are still responsible for the deductible and copayments.)

Non-participating doctors do not accept assignment. They can still treat you, and Medicare will still pay, but they may or may not file the claim for you. If they don’t, you have to pay them, and then file for Medicare to reimburse you. They can charge you more than the Medicare-specified amount.

Opt-out doctors have essentially chosen not to deal with Medicare at all. Medicare will not pay for services they provide. You are responsible for the entire cost.

Does It Get More Complicated Than That?

Sadly, yes. If you are not in Original Medicare but in a Medicare Advantage Plan, which doctors you can see and how much will be paid depends on how the plan is organized. If it is a Private Fee for Service (PFFS) plan, you can see any doctor and the plan will pay, but the amount you pay may differ from doctor to doctor.

If it is a Preferred Provider Organization (PPO) plan, you can see any doctor who participates in the plan, but some doctors are preferred, and some are not. You will pay more for non-preferred doctors.

If it is organized as a Health Maintenance Organization (HMO) plan, you are limited in the doctors you can see to those that are in the organization’s network. The plan will not pay for you to see a doctor who is not in their network.

Does A Plan Have to Provide a Doctor Who Can Treat What You Have?

Original Medicare leaves it up to you to find a doctor who can treat what you have as most accept Original Medicare. Medicare Advantage plans must provide the same range of services as Original Medicare and are responsible for providing a doctor capable of treating you, even if this means a referral to a specialist outside their network.

Does A Plan Have to Pay for Any Doctor I Want to See?

No. If the plan is providing the services you need, it can limit you to doctors that are on its panel, unless it is a PFFS plan.

Give The Coleman Agency A Call Today

You won’t be able to find a Medicare policy that works for you if you don’t shop with a skilled agent. Leverage the help of an insurance professional in your search for coverage and peace of mind. Call The Coleman Agency to get started.