I am new to having Medicare, and I have Original Medicare. What should I consider when I’m looking for a provider for outpatient services?
-Adam (Fairfax, VA)
Dear Adam,
If you have Original Medicare, your Part B costs once you have met your deductible can vary depending on what type of provider you see. There are three types of providers, and each has a different relationship with Medicare. A provider’s relationship with Medicare determines how much you will pay for Part B-covered services you receive from them. The word provider often refers to a physician, but can also refer to other providers of care such as a hospital, dialysis facility, home health agency, or durable medical equipment (DME) supplier, among others.
A participating provider accepts Medicare and always takes assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. To pay the least for services, see a participating provider when possible.
These providers are required to submit a bill (file a claim) to Medicare for care you receive from them. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are steps you can take to help resolve the problem.
If you see a participating provider, you are responsible for paying a 20% coinsurance for Medicare-covered services.
Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
A non-participating provider accepts Medicare but does not agree to take assignment in all cases (but they may take assignment on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for your healthcare services as full payment.
Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of the services you receive (known as the limiting charge). This means that you are responsible for up to 35% (20% coinsurance +15% limiting charge) of Medicare’s approved amount for covered services.
Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15% for most services. For more information, contact your State Health Insurance Assistance Program (SHIP). If you do not know how to contact your SHIP, you can call 877-839-2675 or visit www.shiptacenter.org.
If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount.
The limiting charge rules do not apply to Durable Medical Equipment (DME) suppliers. Call 1-800-MEDICARE or visit www.medicare.gov to find a DME supplier that accepts assignment.
An opt-out provider does not accept Medicare at all and has signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so.
Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
The 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.
Opt-out providers do not bill Medicare for services you receive.
Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date that you received care. If you provider misses the filing deadline, they cannot bill Medicare for the care they provided you. However, they can still charge you a 20% coinsurance and applicable deductible amount.
Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by calling 1-800-MEDICARE or by using Medicare’s Physician Compare tool on www.medicare.gov.
-Marci