Medicare Coverage of Specialty Physicians
Will your specialist’s services be covered by Medicare? That may depend upon:
- Whether your specialist accepts Medicare assignment (she or he agrees to accept the Medicare-approved amount for a service as the entire payment, and won’t bill you above the appropriate deductible and/or cost-sharing amount)
- Whether your specialist is part of your Medicare health plan’s provider network, if this applies to you.
As a Medicare beneficiary, you may have options to how you receive your Medicare coverage.
In order to receive the most from your Medicare Part B coverage (and minimize your out-of-pocket expenses for health-care services), you may want to make sure you go to Medicare specialists when you need specialized care. That is, make sure the specialist accepts Medicare assignment. You can call and confirm this with your specialist.
Generally Medicare doesn’t pay for care you receive from doctors who “opt out” of Medicare. The term “opt out” generally refers to a formal process by which a doctor communicates his or her decision not to accept Medicare payments. Doctors who do not accept Medicare do not submit medical claims to Medicare on behalf of their patients and they are not subject to the Medicare law that limits the amount they may charge patients with Medicare.
How can you find out if you have a Medicare-assigned specialist?
To make sure you have Medicare coverage for a specialist for Medicare-covered services:
- Call your doctor and ask whether he or she accepts Medicare assignment. You can also verify your specialist’s status with Medicare at Medicare.gov. Simply enter your zip code and you can perform a search by your doctor’s name, specialty, or clinic name.
- If your specialist doesn’t accept Medicare assignment, you might have several choices:
- Change to a specialist who accepts Medicare assignment.
- Continue to receive care from your specialist and risk paying more than the Medicare-approved amount for services – in some cases, you might pay the full cost of care out-of-pocket.
- Check to see if a Medicare Supplement (Medigap) plan is available that may pay a portion of the costs for the specialist’s Medicare-covered services. Medicare Supplement plans are offered by private insurance companies and can help you pay out-of-pocket costs for services covered under Medicare Part A and Part B. In most states, up to 10 standardized Medicare Supplement plans may be available. Medicare Supplement Plans F and G might provide coverage for “excess charges” under Medicare Part B for doctors who don’t accept Medicare assignment