A Medicare provider is a physician, health care facility or agency that accepts Medicare insurance. Providers earn certification after passing inspection by a state government agency. Make sure your doctor or health care provider is approved by Medicare before accepting services.
Types of Medicare Providers
Primary care physicians are just one type of Medicare provider. Original Medicare (Part A and Part B), Medicare Advantage (Part C) or Medicare Supplement plans may also cover other services and facilities.
- Doctors and clinicians
- Nursing homes
- Home health services
- Inpatient rehabilitation facilities
- Long-term care hospitals
- Dialysis facilities
What Doctors Are Covered by Medicare?
Original Medicare beneficiaries have access to doctors and health care facilities throughout the United States. Recipients may be limited to a provider network depending on additional coverage purchased.
According to the Kaiser Family Foundation, 93% of primary care providers surveyed accepted Medicare in 2015.
Original Medicare participating providers accept Medicare and most take assignment.
Medicare Providers Under Part C
Many Medicare Advantage plans maintain provider networks.
Most Part C plans, including Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plans, require you to utilize a network of Medicare providers in order to reduce cost. This means that some doctors and health care facilities may be excluded from your network, even if they are Medicare-certified providers.
You can still visit these out-of-network providers — but your care will cost more.
However, these rules don’t apply to emergency care. Medicare Advantage plans must still cover emergency room expenses at in-network rates, even if you use an out-of-network facility.
Each Medicare Advantage plan is required to include an adequate number of in-network providers and hospitals.
To become Medicare certified, providers must complete an application form and pass inspection by a state government agency.
Once Medicare approves a provider, they are assigned a National Provider Identifier and a Medicare billing number.
- Clinical social workers
- Physical therapists
- Physician assistants
- Nurse practitioners
- Occupational therapists
- Speech language pathologists
- Clinical psychologists
Nonparticipating and Opt-Out Providers for Medicare
Not all providers accept Medicare.
Nonparticipating providers accept Medicare but do not agree to take assignment in all cases. These providers can charge up to 15 percent more than the official Medicare reimbursement amount.
In other words, you can still visit a nonparticipating provider — but it’s likely to cost you more money.
It’s important to note that you may be able to cover some or all of these extra expenses — known as excess charges — with a Medigap Supplement insurance policy or Medicare Advantage plan.
Some states don’t allow excess charges at all.
Opt-out providers do not accept Medicare at all. These doctors and health care facilities can charge whatever they want for services and you will be responsible for the entire cost of your care.
Opt-out physicians are required to disclose the full cost of their services to you upfront.
As of October 16, 2020, just under 26,000 providers have opted out of Medicare, meaning those providers can’t see Medicare beneficiaries without disclosing the full cost of care up front and entering into a private contract where the patient agrees to bear responsibility for the full price of services rendered.
5 Cited Research Articles
- Centers for Medicare & Medicaid Services. (2020, October 16). Opt-Out Affidavits. Retrieved from https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z
- Boccuti, C. et al. (2015, October 30). Primary Care Physicians Accepting Medicare: A Snapshot. Retrieved from https://www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/
- Medicare.gov. (n.d.). Contact Information and Websites of Organizations for Medicare. Retrieved from https://www.medicare.gov/talk-to-someone
- Medicare.gov. (n.d.). Find & compare doctors, hospitals & other providers. Retrieved from https://www.medicare.gov/coverage/doctor-other-health-care-provider-services
- Medicare.gov. (n.d.). Doctor & other health care provider services. Retrieved from https://www.medicare.gov/coverage/doctor-other-health-care-provider-services