Janell Sluga Medicare & Individual Health Insurance Account Executive View Bio

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Question:  I have Medicare insurance with a Medigap Plan, as well as a standalone Prescription Drug Plan. I am preparing to travel out-of-state, do all physicians accept Medicare insurance?

Answer: Medicare Part A (which covers hospitalization) and Medicare Part B (which provides medical coverage) has been available since 1965. Healthcare has changed a lot since that time including the addition of Medicare Part D (Prescription Drug coverage) which began in 2006. Many assume that all physicians and hospitals accept participate in Medicare insurance, but that is not true. Medicare insurance is probably the most widely accepted insurance product on the market today, but there are still physicians who do not accept Medicare insurance.

More than 95% of physicians within the United States participate in Medicare insurance. When physicians “participate” with Medicare, they must always accept Medicare “assignment.” This means that they must accept as payment what Medicare allows for as payment for that procedure, office visit, etc. This assignment (payment) is often significantly less than the amount they would bill for that service. Medicare insurance pays the physician directly at 80% of the assigned value of the visit. The 20% left over is billed to you or your secondary insurance. For example, if you see your physician for an office visit which costs $175, Medicare insurance would approve the assignment for this visit at $100, so Medicare insurance would pay $80. You or your secondary coverage would be required to pay the remaining 20%, which in this case, would be $20.

When physicians are “non-participating” providers, they don’t routinely take assignment. These physicians can bill Medicare insurance, but don’t accept what Medicare “assigns” as full payment. This group of physicians will require that you pay more than the Medicare-approved amount. These non-participating physicians can only bill their patients up to 15% above the Medicare insurance assignment amount nationally for their services. In New York State, this additional amount can only be 5% above Medicare insurance assignment. For example, you see your non-participating physician and he bills $175 for the visit. Medicare assignment is $100, so Medicare pays $80. The physician would then expect you or your secondary coverage to pay $25 in New York State, and $35 in most other states. These non-participating physicians can also request full payment up-front for services, and Medicare would then reimburse you with a check for $80.

The third group of physicians are those providers who have “opted out” of Medicare insurance altogether. They cannot bill Medicare insurance for any services (except in some cases of emergencies). This group of physicians are required to inform you of this opt-out in advance, and you are required to sign a written agreement up front, before being seen. This group of physicians can charge whatever they want for services rendered. A common situation for this type of practitioner is Chiropractors – many Chiropractors give you a per-visit charge and do not bill any insurance.

Most physicians in the United States USA participate in Medicare insurance. In the western New York area, it would be difficult to find a non-participating physician l Federal Medicare does not require permissions or referrals for healthcare. So, as you travel around the United States, you can use your Federal Original Medicare insurance card (with few exceptions) anywhere you wish.

It is important to remember that participating in Medicare insurance does NOT indicate participating in the many hundreds of alternative insurance products available such as Medicare Advantage Plans. These plans have their own network of providers and hospitals based on their type of coverage, Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO). This is important to consider when you evaluating your insurance each year, particularly for Medicare Advantage Plans.

If you travel outside of New York State, your Federal Medicare and Medicare Supplement Plan (Medigap) are useful nationally. These products rarely require prior approval or referrals for services. If and when you need care while traveling, your coverage should be completely portable and comprehensive.

When determining if a physician accepts your Medicare insurance plan, show the providers your insurance cards, using the terms Medicare and Medicare Supplement (Medigap) coverage. If you only ask the provider, “Do you take [the insurance carrier name, ex Independent Health]?” then you may not get a correct answer. Be very specific about the insurance product you have when speaking with your providers.

Safe Travels!

 

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Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, fill out the contact form below or call 716.849.1540.