By Bob Moos/Southwest public affairs officer for the Centers for Medicare & Medicare Services
What does it mean when a doctor tells you he has “opted out” of Medicare?
An opt-out doctor is one who doesn’t accept Medicare.
The chances are very slim that you’ll ever find yourself in this particular situation. More than 1 million health care providers throughout the country – the vast majority of them doctors – take Medicare as payment.
True, you’ll occasionally read of some physician who’s thinking about opting out of Medicare. But they are in fact a rare breed.
Still, it’s good to know what to expect if you do happen to visit a doctor who has opted out of the Medicare program.
Doctors who don’t take Medicare can charge you whatever they choose. They don’t submit health care claims to Medicare. Nor are they subject to laws that limit the amount they can charge Medicare patients.
Medicare generally doesn’t pay for services you receive from an opt-out doctor. So, unless it’s an emergency or you need urgent care, you’ll be responsible for the entire cost of your health care.
A doctor who formally opts out of Medicare must have you sign a private contract before receiving any non-emergency care. It basically says you agree to be treated by someone who doesn’t take Medicare patients.
You don’t have to agree to a private contract, of course. You always have the option to go to another doctor who does take Medicare.
But if you do sign the agreement, you should be aware of its meaning:
- The contract applies only to thatparticular doctor.
- Medicare won’t pay any amount for the care you get from the doctor, even if they’re services that Medicare typically covers.
- You’ll have to pay the full amount of whatever thedoctor charges you for the services you get, which could be higher than the Medicare-approved amount.
- If you have supplemental health insurance(sometimes known as a Medigap policy), it won’t pay anything, either.
A physician must tell you if Medicare would pay for the service if you were to get it from another provider who accepts Medicare. Also keep in mind that you can’t be asked to sign a private contract for emergency or urgent care.
Just to be safe, you may want to contact your State Health Insurance Assistance Program to get help before signing a private contract with any doctor or other health care provider. In Texas, that number is 1-800-252-9240.
Most doctors, providers and suppliers accept Medicare, but you should check to make sure that yours does. A customer service representative can assist you at Medicare’s 24-7 helpline. Just call 1-800-633-4227.
Providers who participate in Medicare have almost always signed an agreement to accept the Medicare-approved payment for all Medicare-covered services. In other words, they “accept 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.
Finally, 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.
As I said, the vast majority of physicians treat Medicare patients. But it’s good to know the rules when you find someone who doesn’t.