If you are like most people, you want to have a physician you feel comfortable with, someone who is familiar with you and your medical history, and someone you can trust and speak to openly. Studies have proven that if you have a good relationship with your physician, it is easier to maintain good health habits, and to be more successful at managing health issues.
But what happens when you enroll in Medicare? Will you have to find a new doctor? For most seniors, being able to continue having the same doctor is a key concern when switching over to Original Medicare or a Medicare Advantage healthcare plan. Many people continue getting care from their trusted health care providers, but in some instances, it is not possible to stay with the same physicians you have had for years. You do, however, have options concerning your care providers.
If you are concerned about whether you can continue seeing your family doctor when you enroll in Medicare, here is some information about your options and how Medicare assignment works.
Can you keep your doctor after you enroll in Original Medicare?
If you have healthcare coverage through Medicare Part B, you can go to any physician or health care provider who accepts Medicare assignment and is accepting new Medicare patients. If this is the case for your family health care providers, then you can stay with them. Ask them first if they can include you as a new Medicare patient.
Medicare classifies healthcare providers as either participating, non-participating, or opt-out. Those who are participating providers cannot add extra charges to their medical services. They are required by law to only accept the Medicare-approved amount. On the other hand, non-participating members can add excess charges. An excess charge is any amount that exceeds what Medicare has set as a service charge. Medicare has set these rules to help lower out-of-pocket costs for beneficiaries.
If you wish to receive care from a physician or other healthcare provider who is a non-participating provider, you may do so, but you must pay the excess charge and the copay out-of-pocket. When you visit the non-participating provider you pay the entire service fee amount to them directly. Then, either you or the provider must make a claim to Medicare to get the allowed portion of your costs back.
These expenses can be covered by a Medicare Supplement (Medigap) plan which covers expenses not paid by Original Medicare.
If your health care providers are opt-out providers, that means they may see Medicare patients, but they do not accept any Medicare reimbursement and you are responsible for paying their full fees out-of-pocket.
Can you keep your doctor after enrolling in a Medicare Advantage (Part C) plan?
If you have a Medicare Part C plan, you may be able to keep your doctor, but it depends on what type of Medicare Advantage (MA) plan you have and if your doctor is in the plan’s network of providers.
If you have an HMO, Health Maintenance Organization Plan, you may be required to use healthcare providers that are included in your plan’s set network of providers when your care is not an emergency. In most cases, if you use a physician outside the network, the HMO does not cover the cost and you are responsible for the full amount.
If you have an HMOPOS, HMO with a point of service plan, you may have some allowance to seek medical services outside the plan’s network of providers. In these cases, you may have to pay a higher copayment or coinsurance. You may also need to get approval before the visit.
If you have a PPO, Preferred Provider Organization plan, you can choose between the network of doctors, specialists, and hospitals, or you can choose any provider that is not in their network, but usually at a higher cost. You can also visit specialists without getting a referral or authorization beforehand.
The best case scenario with an MA plan is that your own physician is already in the plan’s network. That way, you can continue to use this provider without a problem. Or, if you have a PPO, you have the freedom to use your doctor.
Before you sign up for a Medicare Advantage plan, you can ask to see a list of the healthcare providers that are included in the plan’s network. This may help you find a plan that enables you to keep the valuable connection you have with your physician.