JustCare

Tag: Participating provider

  • Traditional Medicare protects people from unexpected costs

    Traditional Medicare protects people from unexpected costs

    Traditional Medicare provides enrollees with good protections against unexpected costs. People in traditional Medicare are rarely responsible for the cost of the care they receive, even if Medicare denies coverage. 

    Here are eight Medicare protections that provide people in traditional Medicare financial security.

    1. Federal regulation of provider rates  for people in traditional Medicare. This keeps provider rates down and also keeps down coinsurance and supplemental costs. (Medicare Advantage plans are not able to negotiate provider rates as effectively as traditional Medicare. Although, unlike commercial insurers for working people, they are generally able to piggyback off of traditional Medicare rates.)
    2. A stable of thousands of doctors throughout the US who are “participating providers” (96 percent); they agree to take Medicare’s approved charge as payment in full. (Medicare Advantage plans typically limit their coverage to a small network of doctors within a community, except in emergencies.)
    3. A requirement that non-participating providers, providers who “take Medicare,” but who do not agree to take Medicare’s approved charge as payment in full (4 percent), not charge more than 15 percent above Medicare’s approved charge. Some states have lower limits. (Medicare Advantage enrollees are fortunate today in that out-of-network doctors cannot charge them more than what they can charge people in traditional Medicare. But, Medicare Advantage enrollees usually have to pay the charge for out-of-network care in full out of pocket.)
    4. A requirement that both participating providers and non-participating providers submit their charges directly to Medicare so as to relieve patients from that burden.
    5. A requirement that participating doctors collect their reimbursement directly from Medicare and not charge enrollees upfront for their services. (Medicare Advantage plans also pay their doctors directly, but enrollees may have to go through a referral or prior authorization process in order for their care to be covered.)
    6. A process by which Medicare notifies most supplemental insurers after it pays its share of the charge to pay their share, relieving patients of the burden of submitting claims to supplemental insurers. That said, if enrollees do not have Medicaid or retiree coverage that fills coverage gaps, traditional Medicare enrollees must buy supplemental insurance, “Medigap.” Medigap can easily cost $150 to $200 a month. (Medicare Advantage enrollees usually must pay some amount out of pocket for their care. Copays and deductibles can be as high as $6,700 a year for in-network care alone.)
    7. A requirement that all doctors who provide services to people with Medicare must bill Medicare for their services, unless they have elected to “opt out” of Medicare (<1 percent). And, if they elect to opt out, they must inform their patients in writing and have them sign a waiver agreeing to pay privately for their services in advance of providing them services.
    8. A requirement, in many cases, that if a doctor or other health care provider does not notify a patient in writing in advance that Medicare might not pay for a service, the doctor or other health care provider is liable for the cost if Medicare denies payment. The patient is not responsible for the cost of care. (Medicare Advantage enrollees have a similar protection but are liable for the copay.)

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  • Few doctors opt out of Medicare

    Few doctors opt out of Medicare

    If you have traditional Medicare, you have coverage from virtually any doctor or hospital in the US. While not every doctor takes Medicare, the vast majority of doctors do. That said, there are a small number of doctors who opt out of Medicare; they will only see people with Medicare who agree to pay them whatever they charge out of pocket.

    According to the Centers for Medicare and Medicaid Services (CMS), 1.3 million health care providers take Medicare. And, less than one percent of health care providers opt out of Medicare. In 2017, only 3,732 doctors opted out of Medicare. These doctors tend to practice in wealthy metropolitan areas, where there is a large pool of patients from whom they can receive higher reimbursements for their services.

    If you see a doctor who has opted out of Medicare, Medicare will not reimburse either the doctor or you for any services provided. If doctors who opt out want to provide you with care, they must give you a written document explaining that you must pay privately for the care provided you. And, you must sign this document acknowledging that you understand that Medicare will not cover the service and that you must pay privately for it.

    While few doctors opt out of Medicare, some specialty groups have more doctors who opt out of Medicare than others. The three specialties with the largest percentage of physicians who have opted out of Medicare are: Psychiatry, with 38 percent opting out, family medicine, with 16 percent opting out and internal medicine, with nearly ten percent opting out.

    Of course, there are doctors who take Medicare but who are not taking new Medicare patients. They have a full load of patients or they want to take a balance of Medicare patients and patients with commercial insurance. Whether they take Medicare or commercial insurance, doctors have the right to decide whether they will treat patients.

    Always confirm that the doctors you are seeing take Medicare and, to keep your costs down as much as possible, that they take assignment.  Doctors who take assignment, “participating providers,” agree not to charge more than Medicare’s approved rate for their services. 96 percent of doctors nationwide are participating providers. For a list of doctors and other health care providers who have opted out of Medicare, click here.

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