What Happens When a Doctor Doesn't Accept Your Plan?

2 days ago

6 min read

Finding out that your doctor doesn't accept your Medicare plan can be frustrating, especially if you've been seeing the same doctor for years. The phrase “doesn't accept Medicare” can also mean different things depending on the type of Medicare coverage you have.

If you have Original Medicare, you have a broad choice of doctors and hospitals that participate in Medicare. If you have Medicare Advantage, your plan may have a specific network of doctors and other healthcare providers you are expected to use for routine care.

Before canceling an appointment or assuming you have to find a new doctor, find out exactly what the provider accepts and how your Medicare coverage works.

First, Find Out What “Doesn't Accept” Means

There are several different situations that can be described as a doctor “not accepting Medicare.”

If you have Original Medicare, a doctor may:

Accept Medicare assignment
Accept Medicare but not accept assignment
Opt out of Medicare entirely

These situations have different financial consequences.

A doctor who accepts Medicare assignment agrees to accept the Medicare-approved amount as full payment for covered services. Your normal Medicare cost-sharing still applies. Most doctors and providers accept assignment, but it is worth checking before receiving care.

A non-participating provider accepts Medicare but does not agree to accept the Medicare-approved amount as full payment for every service. You may have to pay more, although federal limits generally restrict how much a non-participating provider can charge for many Medicare-covered services. This additional amount is called the limiting charge.

A doctor who has opted out of Medicare has a different arrangement. Medicare generally won't pay for covered services provided by an opt-out doctor, except in emergencies. You may have to sign a private contract agreeing to pay the doctor directly.

If you have Medicare Advantage, the question is usually different. Your doctor may accept Medicare but not participate in your particular Medicare Advantage plan's network.

That distinction is important because Medicare Advantage plans have their own provider networks and coverage rules.

If You Have Original Medicare

Original Medicare gives you a relatively broad choice of providers. You can generally see any doctor or hospital that takes Medicare anywhere in the United States.

The next question is whether the doctor accepts assignment.

When a provider accepts assignment:

The provider agrees to accept the Medicare-approved amount.
Medicare pays its portion of the covered service.
You pay your applicable deductible or coinsurance.
The provider generally cannot charge you more than the Medicare-approved amount for covered services.

If the provider doesn't accept assignment, ask what you will be expected to pay before receiving care.

For example, you may call a doctor's office and hear:

“We accept Medicare, but we don't accept assignment.”

That doesn't necessarily mean Medicare won't pay anything. It means the provider may charge more than the Medicare-approved amount within the rules that apply to non-participating providers.

If a provider has completely opted out of Medicare, ask about the cost before making an appointment. Medicare generally won't pay for covered services from an opt-out provider, and you may be responsible for the entire cost under a private contract.

You can use Medicare's provider search tool to find doctors and other providers and confirm their Medicare participation.

If You Have Medicare Advantage

Medicare Advantage works differently because your plan may have a network of doctors, hospitals, specialists, and other providers.

For many Medicare Advantage plans, you generally need to use providers in your plan's network for routine, non-emergency care. Some plans allow you to use out-of-network providers, but your costs may be higher.

The rules depend on the type of Medicare Advantage plan.

Plan Type	Using Providers Outside the Network
HMO	Generally requires in-network care for routine services, with exceptions such as emergency or urgent care
PPO	Usually allows out-of-network care, but you generally pay more
PFFS	You can generally use Medicare-approved providers who accept the plan's payment terms
SNP	Rules depend on whether the plan is an HMO or PPO

These are general rules. Your specific plan's Evidence of Coverage explains its network and cost-sharing rules.

This is why a doctor can tell you, “We accept Medicare,” while the office still cannot accept you as a patient under your Medicare Advantage plan. The doctor may participate in Medicare but not have a contract with your particular Medicare Advantage plan.

If you have Medicare Advantage, check your plan's provider directory or call the number on your insurance card before making an appointment.

What If You Want to Keep Your Doctor?

If your current doctor doesn't accept your plan, you have several things to investigate before deciding what to do.

Start by asking the doctor's office:

Do you accept Original Medicare?
Do you accept Medicare assignment?
Are you participating with my Medicare Advantage plan?
Are you currently accepting new Medicare patients?
Can you see me as an out-of-network patient?
If you are out of network, what will I have to pay?
Do you expect to join my plan's network in the future?
Are there other doctors in your practice who accept my plan?

If you have Medicare Advantage and your doctor is out of network, contact your plan before paying for the appointment yourself. Your plan can explain whether the provider is covered, whether you need a referral or prior authorization, and what your expected cost would be.

For an ongoing relationship with a particular doctor, you may also want to compare the cost of changing plans during an enrollment period with the cost and convenience of finding a new provider.

If you're considering changing Medicare coverage because of your doctor, make sure you understand the complete impact of that change. Look at your other doctors, hospitals, prescriptions, premiums, deductibles, copayments, and other benefits before making a decision.

Medicare provides a comparison tool for reviewing Medicare Advantage and Part D plans available in your area.

What About Emergencies?

Emergency care follows different rules from routine doctor visits.

If you have Original Medicare, you can receive covered emergency care from providers even when you're away from your usual area.

Medicare Advantage plans must cover emergency and urgently needed care, including emergency care outside the plan's network. The specific rules for other types of out-of-network care depend on your plan.

If you are experiencing a medical emergency, seek emergency care rather than delaying treatment to check whether a provider is in your network.

For non-emergency care, check your plan's network before receiving services. This can prevent an unexpected bill later.

Get Help Comparing Your Options

If you're having trouble understanding whether a doctor accepts your Medicare coverage, you have several places to get help.

Medicare: You can call 1-800-MEDICARE (1-800-633-4227) with questions about Medicare coverage and providers.

State Health Insurance Assistance Program (SHIP): SHIP provides free, personalized Medicare counseling. SHIP counselors aren't connected to insurance companies or Medicare health plans, and they can help you understand your Medicare options.

Your Medicare Advantage plan: If you have Medicare Advantage, the number on your plan membership card is often the quickest way to confirm whether a specific doctor is in network and what your expected costs will be.

Keep notes when you call. Write down the date, the name of the person you spoke with, and any information they give you about your coverage. If you receive something in writing, keep it with your Medicare records.

Final Thoughts

“Doesn't accept Medicare” can describe several different situations. A doctor may accept Medicare but not assignment, opt out of Medicare entirely, or accept Medicare while being outside your particular Medicare Advantage network.

Knowing which situation you're dealing with makes the next step much easier. Check your coverage before an appointment, ask the doctor's office specific questions, and contact your Medicare plan when you need clarification about network status or costs.

If keeping your current doctor is important to you, include that in your Medicare decisions. Your doctors and hospitals are just as important to compare as premiums and other plan benefits.

Up Next: Sometimes the issue isn't your doctor or your network. You may receive a decision from Medicare or your Medicare plan that you believe is incorrect or unfair. In the next article, we'll look at How to Appeal a Medicare Decision, including the different levels of appeal and how to put together your request.

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