Do I Have to See Specific Providers When I Have Original Medicare vs. Medicare Advantage?

If you have Original Medicare, you can see any provider who accepts Medicare payment. Once you have met your deductible, your Part B costs can vary depending on the type of provider you see. There are three kinds of agreements that Part B providers can have with Medicare about how they will be reimbursed for services they provide to Medicare beneficiaries. To pay the least for services, see a participating provider when possible.

  •  Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. These providers are required to bill Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If you see a participating provider, you are responsible for paying a 20% coinsurance for Medicare-covered services.
  • Non-participating providers accept Medicare but do not agree to take assignment in all cases. They may do so only on a case-by-case basis. Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive. This is known as the limiting charge. This means you could be responsible for up to 35% of Medicare’s approved amount for covered services instead of 20%.
  • Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. Medicare will not pay for care you receive from an opt-out provider except in emergencies. These providers can charge whatever they want for services, but they must follow certain rules to do so. An opt-out provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.

You can find providers who accept Medicare payment and find out whether they are participating by calling 1-800-MEDICARE or by using Medicare’s Physician Compare tool on www.medicare.gov.

If you have a Medicare Advantage Plan, you may be restricted to a network of providers in order to pay the least amount for your care. Each type of Medicare Advantage Plan has different network rules. A network consists of doctors, hospitals, and medical facilities that contract with a plan to provide services. There are various ways a plan may manage your access to specialists or out-of-network providers. Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan.

Your Medicare Advantage Plan is required to cover emergency and urgent care anywhere in the U.S. without imposing additional costs or coverage rules (such as prior authorization). This means that if you seek emergency care from an out-of-network provider, your Medicare Advantage Plan must cover the care as if you had gone to an in-network provider. Medicare Advantage Plans define an emergency by the prudent person standard. Prudent means acting with care or thought about the future. This standard ensures that even if your condition turns out not to be a medical emergency, it will still be covered as long as a prudent person would have assumed it was an emergency at the time you got care.

It is important to know that not all Medicare Advantage Plans—even plans of the same type—work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.
This table provides a general overview of provider access rules for HMOs, PPOs, and PFFS plans:

 HMOPPOPFFS
Do I need to get a referral before I can see an in-network specialist?Yes, usuallyNoYes
Will the plan pay for care from a doctor or hospital that is not in the plan’s network?No, unless you need urgent or emergency care or if you have a Point of Service (POS) option that allows you to use out-of-network providersYes, but you will pay more, unless it is an emergencyYes, but you will usually pay more and the provider must agree to treat you, unless it is an emergency

Note: This chart does not include SNPs or Medicare MSA plans. A SNP is a managed care plan that serves people with special needs. In an MSA plan, you can go to any doctor or hospital willing to accept the plan’s fees. If you are considering joining a SNP or an MSA, ask about that specific plan’s network rules.

Read More: What is Considered a Supplemental Benefit?
Learn About: How Does Original Medicare and Medicare Advantage Work?
Return to: Medicare Advantage

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This content was created and copyrighted by the Medicare Rights Center ©2020. Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities. These materials are presented here with support from YourMedicare.com and may not be distributed, modified or edited without Medicare Rights’ consent.

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