When Your Doctor Doesn’T Take Medicare

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David Sayen

What does it mean when a doctor tells you he or she has “opted out” of Medicare?

An opt-out doctor is one who doesn’t accept Medicare. Doctors who have opted out of Medicare can charge their Medicare patients whatever fees they choose. These doctors don’t submit any health care claims to Medicare. In addition, opt-out doctors aren’t subject to Medicare laws that limit the amount they can charge their patients.

More than 1 million health care providers throughout the United States — the vast majority of them doctors — accept Medicare as payment.

But when you visit a doctor who has opted out of Medicare, you pay the entire cost of your care, unless it’s an emergency or you need urgent care. Generally, Medicare doesn’t pay for health care services you receive from an opt-out doctor.

If your doctor has formally opted out of Medicare, he or she must have you sign a private contract stating that you agree to receive care from a doctor who doesn’t accept Medicare. This private contract only applies to services provided by the doctor or other provider who asked you to sign it.

You don’t have to sign a private contract. You can always go to another provider who does take Medicare. If you do sign a private contract with your doctor or other provider:

• Medicare won’t pay any amount for the services you get from this doctor or provider, even if it’s a Medicare-covered service.

• You’ll have to pay the full amount of whatever this provider charges you for the services you get.

• If you have a Medicare Supplement Insurance (Medigap) policy, it won’t pay anything for the services you get. Call your insurance company before you get the service if you have questions.

A physician or other provider must tell you if Medicare would pay for the service if you get it from another provider who accepts Medicare. Your provider also must tell you if he or she has been excluded from Medicare.

And keep in mind that you can’t be asked to sign a private contract for emergency or urgent care.

You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider. Your local SHIP number is available by calling 1-800-MEDICARE (1-800-633-4227).

Most doctors, providers and suppliers accept Medicare, but you should always check to make sure. (You can always get services not covered by Medicare if you choose to pay for them yourself.)

Providers who participate in Medicare have signed an agreement to accept the Medicare-approved payment for all Medicare-covered services. In other words, they “accept assignment.”

Here’s what it means when your doctor, provider or supplier accepts assignment:

• Your out-of-pocket costs may be less.

• Your provider agrees to charge you only the Medicare deductible and coinsurance amount and usually wait for Medicare to pay its share before asking you to pay your share.

• Your provider has to submit your claim directly to Medicare and can’t charge you for submitting the claim.

If you have a Medicare Advantage plan, also known as a Medicare private health plan, you should see doctors within your plan’s network. You typically pay the least if you go to a doctor who’s in the plan network. Check with your plan to see what rules apply. 

About the author

David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

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