Key Takeaways
Nationally, only 1% of non-pediatric doctors in the U.S. have opted-out of Medicare. 42% of those who have opted-out are psychiatrists.
Most doctors accept new Medicare patients, with acceptance rates of 89% nationally among office based physicians.
States with the lowest percent of physicians accepting new Medicare patients include Utah and Oregon at 79%, then California, Nevada, Washington, Alaska, Maine and Maryland at between 80% and 82%. Followed by Montana, New York and Connecticut at between 83% and 84%.
If your healthcare provider accepts Medicare Parts A and B, they will also accept any Medicare supplement plan from any insurance company.
According to kff.org, only 46% of doctors accept some Medicare Part C plans (aka Medicare Advantage). Even then, they may not accept your plan. The networks of doctors can vary depending on each Medicare plan and can change annually.
Only 22% of Medicare Advantage Plans have a network that consists of at 70% of doctors that accept Medicare in their area. 43% of Advantage plans have networks that include only 30% to 69% of area physicians that accept Original Medicare. A full 35% of Advantage plans have networks limited to less than 30% of doctors that accept Medicare in their area of coverage.
As always, asking questions and doing your research is key to choosing the best Medicare coverage. Medigap Seminars is an independent Medicare insurance expert. We advise on both Medicare supplement plans and Advantage plans. Even more, our services are free to the consumer. Talk to a Medicare expert today!
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Important Stats
Medicare enrollees age 65 and older are the fastest-growing age demographic in the U.S.
17% of the U.S. population was age 65 or older as of 2020, and that number is expected to increase to 22% by 2040.
In 2020, 5 million people aged 65+ lived below the poverty level, and another 2.6 million were considered “near-poor.” These are people who generally cannot afford a Medicare supplement.
Understanding Medicare Acceptance
Medicare acceptance is a crucial aspect of healthcare for seniors and individuals with disabilities. Understanding how Medicare acceptance works can help you navigate the system and ensure you receive the best possible care.
When a healthcare provider accepts Medicare, it means they agree to the terms and conditions set by Medicare for payment and services. Providers who accept Medicare agree to the Medicare-approved amount as full payment for covered services, which can save you money and simplify the billing process.
There are two main types of Medicare acceptance: participating and non-participating health care providers. Participating providers accept Medicare assignment, meaning they agree to the Medicare-approved rate for services. When they provide Medicare covered services, they bill Medicare directly. Then Medicare and the supplement pay the health care providers directly. This ensures that you are not billed for more than the Medicare-approved amount, making it easier to manage your healthcare expenses.
Non-participating providers, on the other hand, do not accept Medicare assignment and can charge up to 15% more than the Medicare-approved amount on some health care provider services. This can lead to higher out-of-pocket costs and a more complex billing process, as you may need to pay upfront for Medicare covered services and seek reimbursement from Medicare.
It’s also important to note that some doctors may choose to opt out of Medicare entirely, meaning they do not accept Medicare patients at all. In such cases, you would need to find a different healthcare provider who accepts Medicare to ensure your services are covered.
To find a doctor who accepts Medicare, you can use the Medicare website’s provider search tool, contact your local Medicare Administrative Contractor, or call Medicare’s toll-free number. Additionally, if you have a Medicare Advantage plan, check with your plan provider to ensure your preferred doctors are in-network.
Understanding Medicare acceptance can help you make informed decisions about your healthcare and ensure you receive the best possible care without unexpected costs.
Do Most Doctors Accept Medicare Assignment?
Many Medicare beneficiaries are concerned about being charged an Excess Charge. An excess is limited to 15% of the bill and can only be billed by a doctor who has opted out of accepting Medicare Assignment.
Very few doctors who accept Medicare do not accept assignment. According the the latest research, less than 3% of physicians who accept Medicare covered services do not accept Medicare Assignment. Of that 3%, nearly half are mental health professionals.
Even then whether or not you are billed an excess charge is negotiable. Keep in mind also that excess charges are only possible with outpatient care and physican services. There are no excess charges for inpatient services.
According to kff.org, 99.60% of bills submitted by physicians who can charge an excess charge do not include an excess charge. Think about that!
The bottom line: their are so few doctors who can and will charge a Medicare Part B excess charge, that the probably of such a charge is less than 1%. That means that in your entire Medicare experience you are unlikely to ever encounter a doctor who can charge an excess charge.
There are no Part A excess charges.
How Many Doctors Have Opted Out of Medicare?
A decade ago, 3% of doctors opted out of Medicare, but recent reports indicate a decrease in that number. Currently, approximately 1% of doctors chose to opt out. Private medical insurance companies play a significant role in administering Medicare Advantage plans. Factors such as hospitals acquiring medical practices and new doctors preferring to join medical groups (which involves them in Medicare) contribute to this trend.
Medicare age patients are the largest and fastest growing demographics of medical patients. In addition, Original Medicare and Medigap plans pay within days or weeks of receiving a bill. Months faster than the average turnaround of private health insurance or Advantage plans.
In all states except Alaska, Colorado, and Wyoming, the percentage of physicians who have opted out of the Medicare program is less than 2% in each state.
So, do all doctors accept Medicare? No, but almost all.
How Many Doctors Accept New Medicare Patients?
According to KFF, the independent source for health policy research, polling, and news, most non-pediatric office-based physicians accept new patients with Medicare coverage, as well as new private insurance patients.
Based on an analysis using data from the 2019 National Electronic Health Records Survey (NEHRS), it was found that 89% of physicians accepted new patients who use Medicare in that year. Similarly, 91% of physicians accepted new patients with private insurance.
Among primary care doctors, the acceptance rates were slightly lower but still comparable, with 83% accepting new patients with Medicare versus 86% accepting new patients with private insurance.
The analysis also revealed that the percentage of non-pediatric office-based physicians accepting new patients with Medicare remained consistent between 2011 (88%) and 2019.
If you need Medicaid services, however, you may have more trouble finding a primary care doctor who accepts your insurance. Only 45% of primary care physicians accept new Medicaid patients according to KFF. One-third of primary care doctors won’t take new patients on Medicaid.
Should I Be Concerned That My Doctor Is Paid Less Through Medicare System?
There are always discussions regarding the adequacy of Medicare payments for physicians and concerns about potential access issues if Medicare rates were implemented.
However, cash flow is key to a medical office survival. Unlike other types of health insurance, Original Medicare pays within 2-weeks of receiving a bill. Most Medigap plans pay over 85% of claims within 48%. That creates a positive cashflow that is key to any medical office sustainability.
Do Doctors Have to Accept Medicare?
Medical providers are not required to accept Medicare. The decision to accept or not accept Medicare is up to each individual doctor or healthcare provider.
How Do I Find a Doctor Who Accepts Medicare Patients?
To find a doctor who accepts Medicare, you can: 1) Use this tool on the federal government Medicare website: Click Here to Medicare Compare official Website
Contact your local Medicare Administrative Contractor (MAC) for a list of doctors who accept Medicare in your area.
Call Medicare’s toll-free number at 1-800-MEDICARE (1-800-633-4227) to discuss your health insurance. 4) Talk to your primary care physician who might be able to recommend other doctors who accept Medicare patients.
If you have a Part C plan or a supplemental insurance plan, check with your insurance for a list of doctors who participate in their network. Only about 46% of doctors who work with Medicare will accept any Advantage plan. Even then, they may not accept your Advantage plan. Remember to verify with the doctor’s office directly that they still accept your Advantage plan, as network participation can change annually.
What is Medicare Assignment?
When a medical professional chooses to work with Medicare, they have two options for annual contracts: Participating Provider or Non-Participating Provider.
A Participating Provider agrees to accept the Medicare-approved rate for services and bills Medicare directly, not the patient. This agreement is known as Medicare assignment. When a doctor accepts assignment, thy are called a Participating Provider.
By contract, if a doctor accepts assignment, they are not allowed to charge excess fees.
As a benefit of being doctor who accepts assignment, Medicare handles all the billing process. The doctor only bills Medicare, which pays its share within a few weeks. Medicare will also electronically communicate with a Medigap plan (if you have it) and provide all the instructions to the plan on what to pay, when, and to whom.
What If My Doctor Does Not Accept Assignment?
When a doctor intends to bill the patient more than the Medicare assignment rate, they can choose a contract as a Non-Participating Provider with Medicare. Being a non-participating doctor in the Medicare program means they are not required to accept assignment and can charge excess fees.
Under the non-participating contract, Medicare doctors can charge a maximum of 15% more than the approved Medicare reimbursement rate for covered services.
This is a less-than-ideal scenario for all the parties involved.
Medicare discourages doctors from becoming non-participating providers by implementing penalties.
To begin with, they reimburse non-participating providers 5% less than they pay participating providers. Then, non-participating providers can only bill a maximum of 15% more than the Medicare reimbursement rate. At the end, the doctor will receive only 9.25% more compared to accepting Medicare assignment.
A significant consequence of being a Non-Participating medical provider is that Medicare will not handle the billing process as a one-stop biller. Although the doctor’s office still needs to bill Medicare, Medicare will not forward the bill to Medigap plans. Since the doctor lacks a contract with Medigap plans, they cannot bill them either. Instead, they usually require patients to pay for services upfront and then seek reimbursement directly from their supplement insurance company.
A physicians office must notify you ahead of time or display a conspicuous sign that alerts you to a potential excess charge. .
Will All Doctors Accept My Medicare Supplement Plan?
If a doctor accepts Original Medicare and Medicare assignment, they are required to accept any Medigap plan that you have, from ANY insurance company. Remember, they don’t bill the Medigap plan, Medicare does.
According to the Kaiser Family Foundation report, Medicare enrollees who do not have supplemental insurance face challenges in finding doctors who accept Medicare without a supplement. So it’s recommended that these patients consider investing in Medicare supplement insurance.
What If I Have a Medicare Advantage Plan?
Not all doctors accept Medicare Advantage plans. Part C Advantage plans have networks of doctors and healthcare providers who have agreed to accept the plan’s terms and conditions. These networks vary between different Part C plans.
Do Medicare Advantage Plans Have Large Networks?
One of the weakness of Advantage Plans is their limited network. Medicare Advantage Plans replace your Original Medicare with similar coverage operated by private insurance companies.
Only 22% of Advantage Plans have a network that consists of at least 70% of doctors that accept Medicare in their area. 43% of Advantage plans have networks that include only 30% to 69% of area physicians that accept Original Medicare. A full 35% of Advantage plans have networks limited to less than 30% of doctors that accept Medicare in their area of coverage.
When you have a Medicare Advantage plan, you need to review the plan’s provider directory or contact the plan directly to verify if your preferred doctors and healthcare providers are in-network. Seeing an in-network provider typically results in lower out-of-pocket costs and ensures that the services are covered by your Advantage plan for a Medicare-approved amount.
You will also want to check the plans drug coverage and prescription drug costs as this can change every year.
What Percentage of Doctors Accept Medicare Advantage Plans?
According to kff.org, only 46% of doctors that are contracted with Medicare, accept some Advantage plans (aka Medicare Advantage). Even then, they may not accept your plan. The networks of doctors can vary depending on each Medicare plan and can change annually.
Do Doctors Accept All Medicare Advantage Plans?
Doctors do not normally accept all Advantage plans. These Medicare plans have their own networks of doctors and healthcare providers who have agreed to accept the terms and conditions of specific plans. Provider network and health coverage can vary between different Advantage plans.
Unlike Original Medicare, Part C medical providers enter into separate annual contracts with doctors and healthcare networks for medical services.
Check with individual doctors and healthcare providers to see if they participate in the specific Advantage plan you are interested in.
Feel free to reach out to us with any other questions or concerns about your health insurance! Not only do we have extensive Medicare insurance expertise, but we’re also on a genuine mission to help you save money on Medicare every month.
Sources
KFF: Primary Care Physicians Accepting Medicare: A Snapshot
Medicare Advantage: How Robust Are Plans’ Physician Networks?
