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Choosing Doctors and Other Providers

Oct 24, 2023 | Shea Corti

Depending on how you get your Medicare coverage, you will have different considerations when choosing health care providers, such as doctors, hospitals, or medical equipment suppliers. Let’s discuss the factors you should consider so that your care is covered at the lowest cost. With these factors in mind, you can choose your next health care provider.

If you have Original Medicare, choose a participating provider.

If you have Original Medicare, your health care costs depend, in part, on the type of provider you see. There are three types of providers, and each has a different relationship with Medicare. To pay the least for your care, 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. Participating providers must submit a bill to Medicare when you receive care. Medicare then processes the bill and pays the provider 80% of the cost of your care. You are then responsible for the other 20% of the cost.
  • Non-participating providers, on the other hand, accept Medicare, but do not have to take assignment. This means they can charge up to 15% more than Medicare’s approved amount for services. In other words, you could owe up to 35% of the cost of Medicare’s approved amount for services, instead of just 20%.
  • Opt-out providers do not accept Medicare at all. These providers 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, following certain rules. If you see an opt-out provider, they must give you a private contract describing their charges. This contract also confirms that you understand that you are responsible for the full cost of your care and that Medicare will not reimburse you.

If you have Original Medicare, call 1-800-MEDICARE or visit www.Medicare.gov for help finding participating providers near you.

If you have a Medicare Advantage Plan, choose an in-network provider.

If you have a Medicare Advantage Plan, your plan must cover the same health care services and items as Original Medicare. Your plan can do so with different costs and restrictions, though.

Each type of Medicare Advantage Plan has different network rules. A network is a group 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. For example, if you see a provider who is outside your plan’s network, you may have to pay more than you would for an in-network provider. You could also be responsible for paying the full cost of your visit, depending on what type of Medicare Advantage Plan you have. Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan type.

It’s important to note that not all Medicare Advantage Plans 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.

If you have Medicare Part D, use an in-network pharmacy with preferred pricing.

Medicare Part D is Medicare’s prescription drug benefit. Part D is offered through private companies either as a stand-alone plan if you have Original Medicare, or as a set of benefits included with your Medicare Advantage Plan. Part D plans generally have networks of pharmacies that they work with to provide you with covered medications. Many pharmacy networks include pharmacies that offer preferred pricing. You typically pay less for your prescriptions at these pharmacies. If you need to find an in-network pharmacy or if you have any issues accessing your covered medications at the pharmacy, contact your Part D plan.

Still have questions?  

Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.

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