Ensure an Easy Transition to Medicare

Medicare can simplify health insurance costs and decisions if you’re age 65 or older as long as your preferred health care providers are part of the program.

Happy female doctor checking an older male patient's blood pressure

by NEA Member Benefits

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Key takeaways

  • Doctors can choose to accept Medicare payments in full, in part, or elect to opt out of the program.
  • The vast majority of primary care physicians continue to accept Medicare for all covered services.
  • Medicare acceptance rates may be somewhat lower in wealthy urban areas.
  • If your doctor does not accept Medicare, you can pay out of pocket or look for a new physician.

Even though Baby Boomers are notorious for refusing to age, many of them are looking forward to turning 65 so they can move to Medicare for their primary health coverage. In general, Medicare premiums are less expensive than private health insurance, and if you opt for prescription drug coverage and a Medicare Supplement policy you may have zero out-of-pocket expense when you visit your doctor or the hospital.

Partly because Medicare pays lower provider reimbursement rates than private insurance, and requires doctors to jump through lots of administrative hoops, the participation rate in the program isn’t quite as universal as it was a decade ago. But overall, it’s not as difficult to find doctors who accept Medicare as some media reports make it out to be.

Categories of doctor participation in Medicare

There are three ways doctors work with Medicare:

1. Accept assignment. This means a doctor agrees to accept Medicare-approved reimbursements as payment-in-full for all covered services. This is what most people want from their doctors.
2. Non-participating. This is a bit of a misnomer because these doctors do accept Medicare payments but they don’t necessarily accept it as full payment. If a non-participating doctor charges you $200 and Medicare allows $150 for the service, you will have to pay the $50 difference plus any copays.
3. Opt-out.  Doctors who opt out don’t submit any bills to Medicare. You are responsible for paying the entire cost of services.

Are there more Medicare doctors or less?

Despite predictions about people having trouble finding Medicare “accept assignment” doctors, research by the Henry J. Kaiser Family Foundations in 2015 found that more than 9 in 10 non-pediatric primary care physicians accept Medicare—about the same percentage as those who accept private insurance.

There may be pockets of the country—primarily in wealthier urban areas—where it’s a little harder to find doctors who accept Medicare. For example, New York City had a 76% accept assignment rate for Medicare beneficiaries in 2017, while Fargo, North Dakota had a 100% acceptance rate, according to Merritt Hawkins, a physician search firm.

Rather than opt out of Medicare, some doctors simply cap the number of Medicare patients they are treating, effectively limiting access for new Medicare beneficiaries. In a 2016 survey, the Texas Medical Association found that 35% of its members were not accepting new Medicare patients, up from 22% in 2000.

What to do if your doctor does not “accept assignment”
To avoid any opt out surprises, ask your physicians if they plan on continuing to accept Medicare. If the answer is “no,” start your search for new doctors before you turn age 65 so the transition will be smoother when you switch over to Medicare coverage.

  • Check the Physician Compare Directory on medicare.gov. You can search for Medicare doctors by ZIP code. It’s a good idea to call doctor candidates to make sure they are still on board with the program.
  • Ask for referrals. Ask your trusted doctors for names of other physicians who may accept Medicare.
  • Negotiate lower fees. If you just can’t leave your opt-out doctor, ask for discounts for prompt cash payments. Many doctors will lower fees if they know you have to pay out-of-pocket.
  • Consider urgent care or clinics for routine medical issues. Most clinics accept Medicare, but check those in your area in advance.
  • Pay for a concierge. Some physicians are converting their practice to a concierge model, where patients pay a monthly or annual fee and then receive certain medical services. This option generally is for wealthier patients who don’t want to feel like they are part of a large volume practice in which doctor-patient time is limited.

Understand your options and be proactive

The vast majority of seniors heading into the Medicare system will find it a seamless transition with their current health care providers. If you are among the few who must search for new doctors, with a little bit of pre-planning you should be able to build trusted relationships with good doctors before you get your Medicare card.

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