Medicare Minute: Choosing Doctors and Facilities

Depending on your coverage, you will have different considerations when choosing health care providers like doctors, hospitals, or medical equipment suppliers. Follow this link to review some of these factors, so you can get your care covered at the lowest cost. 

Even with this information in hand, remember to trust yourself and your feelings when choosing your health care providers. For instance, just because a provider is in network doesn’t mean they will be a good fit for you. You may have to try multiple providers before finding one who you trust and who fits your needs.

If you have Original Medicare, choose a participating provider.

There are three types of providers, and each has a different relationship with Medicare. To pay the least for your care, see a participating provider when possible.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. Participating providers must submit a bill to Medicare when you receive care. Medicare then processes the bill and pays the provider 80% of the cost of your care. You are then responsible for the other 20% of the cost.

Non-participating providers, on the other hand, accept Medicare, but do not have to take assignment. This means they can charge up to 15% more than Medicare’s approved amount for services. In other words, you could owe up to 35% of the cost of Medicare’s approved amount for services instead of just 20%.

Opt-out providers do not accept Medicare at all. These providers have signed an agreement to be excluded from the Medicare program. Medicare will not pay for care you receive from an opt-out provider, except in emergencies, and will not reimburse you. These providers can charge whatever they want for services, following certain rules.

Choosing Doctors and Other Providers

If you have Medicare Advantage, choose an in-network provider.

A network is a group of doctors, hospitals, and medical facilities that contracts with a plan to provide services. Each type of Medicare Advantage Plan has different network rules. There are various ways a plan may manage your access to specialists or out-of-network providers. For example, if you see a provider who is outside your plan’s network, you may have to pay more than you would for an in-network provider. You could also be responsible for paying the full cost of your visit, depending on what type of Medicare Advantage Plan you have.

Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan type. It’s important to note that not all Medicare Advantage Plans work the same way. Make sure you understand a plan’s network and coverage rules before enrolling. If you have questions, contact your plan for more information.

If you have Part D, choose an in-network pharmacy and look for pharmacies with preferred cost sharing.

Part D plans generally have networks of pharmacies that they contract with to provide you with covered medications. Many pharmacy networks include pharmacies that offer lower “preferred” cost sharing. You typically pay less for your prescriptions at these pharmacies. If you need to find in-network pharmacy or if you have any issues accessing your covered medications at the pharmacy, contact your Part D plan.

Need help finding doctors and other providers?

• If you have Original Medicare: Call 1-800-MEDICARE (633-4227) or use Medicare’s online Care Compare tool.
• If you have Medicare Advantage: Contact your plan for a list of in-network providers.
• For more assistance, contact your State Health Insurance Assistance Program (SHIP). In Southwest Florida, that is SHINE (Serving Health Insurance Needs of Elders), call 1-866-413-5337 or email shineinfo@aaaswfl.org.

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