Medicare clients often look to their agent for guidance when navigating the complexities of the government healthcare system.
One complexity is finding doctors and providers that accept Medicare assignment.
Originally published November 22, 2021. Updated November 22, 2022.
For example, clients with a Medicare Supplement Plan N are exposed to excess charges if they see a non-participating provider.
In addition, certain services must be received by a Medicare-participating provider in order for Medicare and a supplement to pick up the tab (think home health care agencies).
Finally, all Medicare Supplement clients will be responsible for their medical bills if they see a provider who has opted out of Medicare altogether.
Thankfully, there's a simple way to coach your clients on finding Medicare-participating providers: Medicare's Care Compare tool.
New to Medicare sales? Brush up on your Medicare education by reading Medicare Basics for New Senior Market Insurance Agents.
What Is Medicare Assignment (And Why Should Med Supp Clients Care)?
First thing's first: what is Medicare assignment, and why should Med Supp clients care?
Medicare has a payment schedule called a Physician Fee Schedule, and they decide what they're willing to pay for items and services.
Note: You can access this Physician Fee Schedule here. Fair warning: it's a little complicated.
This is essentially a set "price list" for every item and service Medicare covers. The exact price varies by location, and Medicare releases a new Physician Fee Schedule annually.
Here's an example of what comes up when searching the HCPCS code for colonoscopy:
Doctors can choose to accept these rates, not accept them but still work with Medicare, or opt out from Medicare altogether.
Providers can accept those Medicare-approved amounts as full payment for covered services. We call these participating providers, because they accept Medicare assignment.
According to many estimates, about 97% of all providers agree to accept Medicare assignment.
Any client with a Medicare Supplement has the freedom to see any provider that accepts Medicare assignment. Thankfully, the vast majority of providers fall under this category.
Providers that agree to accept Medicare but not all of their approved amounts are non-participating providers.
Non-par providers can charge more than the Medicare-approved amount in the form of an excess charge, which is up to 15% over the Medicare-approved amount.
Note: Some states don't allow excess charges—they include:
- Rhode Island
- New York
Folks with a Medicare Supplement Plan N will have to pay all excess charges if they see a non-participating provider.
Medicare Supplements F and G cover excess charges, so there is no financial impact on the client.
Providers That Opt-Out of Medicare
Finally, providers can decide to opt-out of Medicare altogether. This is extremely rare, with less than 1% of physicians deciding to opt-out.
According to KFF research, psychiatrists account for the largest share (42%) of all non-pediatric physicians who opted out of Medicare in 2020.
If a provider opts out, Medicare won't pay for any covered items or services unless it's an emergency. Medicare Supplements "follow" Medicare, so if Medicare won't pay for it, neither will the supplement.
If a client has a Medicare Supplement plan, they ideally don't want to see a provider that opts out of Medicare. If they do, they will be responsible for all expenses.
You can help clients find providers that have opted out of Medicare using this form on Medicare.gov.
Here's an example list of providers who have opted out of Medicare. You'll notice they're all specialists.
Keep in mind a provider has to formally opt-out of Medicare to make it onto this database.
What is Medicare Care Compare?
It's important that your clients see doctors who accept Medicare. This will ensure they keep their out-of-pocket costs to a minimum.
You can help your clients find doctors and providers that accept Medicare by using Medicare's Care Compare tool. The tool allows anyone to search by location and provider type to uncover which providers accept Medicare.
You can even enter a keyword, such as the last name of a physician, to filter down the search results.
Using the Care Compare tool, you can find:
- Nursing homes
- Home health services
- Hospice care
- Inpatient rehabilitation facilities
- Long-term care hospitals
- Dialysis facilities
Here's an example:
The results page offers a map view along with some basic information about the providers.
You can see next to the dollar sign icon that these providers accept Medicare assignment. You can also filter by doctors that accept Medicare assignment in the following drop-down:
Next time a client wants to know if they can see their favorite dermatologist under their Medicare Supplement plan, you know where to look!
Of course, you can also call any provider to confirm their acceptance of Medicare, but you may have to wait on hold or wait for a callback.
Share Medicare Care Compare Information With Clients
Get the word out about the Care Compare tool with your clients.
Here is some copy you can use for a Facebook post or email newsletter. Don't forget to download the corresponding image, sized for use on Facebook. To download the image, right click and select "Save Image As."
Need help selecting doctors and clinicians that accept Medicare? Try out Medicare's Care Compare tool. Search by location and provider type to uncover which providers accept Medicare in your area.
Here's what your post will look like:
Helping Medicare Advantage Clients Find In-Network Providers
For clients who choose Medicare Advantage, they also need help ensuring their current doctors, physicians, specialists, and hospitals are in the plan's network.
Thankfully, national carriers are expanding their networks every year, and networks are becoming less and less of an issue. However, it's still very important to check, especially if your prospect or client is considering a more regional plan.
The best way to double check a provider network is to go to the MA carrier's website and use their provider/network search tools. As an example, Aetna has a provider search tool that allows you to type in a name, specialty, procedure, or medication.
It's also not a bad idea to then call those important providers and double-check from their end that they are still accepting that plan.
Many clients are fine selecting a new physician or specialist within network. However, if they already have doctors and physicians they love, you'll want to take this extra step to make sure their potential new MA plan is compatible.
We are always looking for ways to add value to your Medicare clients. Help them find and select doctors that work with Medicare using the Care Compare tool.
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