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Doctors and Medicare Advantage

It’s good if you’re wondering ‘Does my doctor accept Medicare Advantage?’ Making sure that the healthcare providers that you frequent accept your Medicare Advantage plan is an important way to keep your medical costs down. The type of Medicare Advantage plan (e.g. HMO), and any provider network associated with the plan, determines if and how your doctor accepts Medicare Advantage.

Medicare Advantage Coverage

In non-emergency and non-urgent situations it is important that you go to a doctor (or healthcare facility or other healthcare service provider) that belongs to your plan or accepts your plan even if the plan does not have a provider network. Depending on the particular Medicare Advantage plan you have (but especially with HMO and PPO plans), going to a healthcare provider that does not belong to your plan could mean that your services are not covered and, consequently, increase your out-of-pocket costs. Additionally, certain plans may require you to get a referral to see a specialist in order to avoid higher costs. Always check with your plan before seeing a new healthcare provider.

Types of Medicare Advantage Plans

  • HMO Plans: Members of HMO plans choose a primary care physician (PCP) within a network of providers. The PCP will refer you to HMO specialists as needed.
  • PPO Plans: A PPO is much like an HMO except you will not need to choose a PCP upon entering the network of healthcare providers.
  • PFFS Plans: A Private Fee-For-Service plan has no PCP and no network of doctors. You can use any Medicare-approved doctor, but payment terms for each service can change between visits.
  • Special Needs Plans: A Medicare Advantage plan that is exclusively designed for the unique needs associated with one of the following categories: A type of chronic or disabling health condition covered by SNPs (e.g. diabetes), enrollment in both Medicaid and Medicare simultaneously, and residence in certain institutions such as a nursing home. This type of plan is also referred to as a SNP.

Accepting Assignment

Does your doctor accept Medicare assignment for medical services and procedures? He/she doesn’t have to. Doctors have three options when it comes to assignment.

  • Participating: If a doctor is participating in assignment he or she has agreed to accept the Medicare-allowed amount as full payment for the services rendered. Normal Medicare deductibles and/or co-payments still apply for the Medicare beneficiary.
  • Nonparticipating: A nonparticipating doctor can either choose to accept the Medicare assignment amount for a service or not. If your doctor doesn’t accept the Medicare assignment amount, he or she can charge no more than 15% above the Medicare-approved fee for the service and the Medicare beneficiary is responsible to pay the extra amount along with any deductible or co-payment already required by Medicare.
  • Opt Out: These doctors are not enrolled in Medicare at all and can charge self-determined costs for services. They are not allowed to bill Medicare for any services, and if you see a doctor who has opted out of Medicare, you will pay the entire bill.

Additional Medicare Advantage Coverage

While Original Medicare does not cover routine vision, hearing, or dental, you may ask your Medicare Advantage plan if it covers any of these services. There are many Medicare Advantage plans across the nation that do offer extra coverage in one or more of these areas.