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. Other services and facilities may also be covered by Original Medicare (Part A and Part B), Medicare Advantage (Part C) or Medicare Supplement plans.
- 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 generally have access to doctors and health care facilities throughout the United States. Recipients usually aren’t limited to a provider network.
According to the Kaiser Family Foundation, 93 percent of primary care providers surveyed accepted Medicare in 2015.
Original Medicare participating providers accept Medicare and always take assignment. This means Medicare pays the provider 80 percent for Medicare-covered services and the patient contributes a 20 percent copayment.
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 and urgent care expenses at in-network rates, even if you use out-of-network facilities.
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 a Medicare provider is approved, they are assigned a National Provider Identifier and Medicare billing number.
- Clinical social workers
- Physical therapists
- Physician assistants
- Nurse practitioners
- Occupational therapists
- Speech language pathologists
- Clinical psychologists
Nonparticipating and Opt-Out Providers
Not all doctors 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 these extra expenses — known as excess charges — with a Medigap insurance policy or Medicare Advantage plan.
Also, 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 are held 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 they can’t see Medicare beneficiaries without entering into a private contract where the patient agrees to pay full price.
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/contacts/
- Medicare.gov. (n.d.). Find & compare doctors, hospitals & other providers. Retrieved from https://www.medicare.gov/coverage/doctor-other-health-care-provider-services
- Nedicare.gov. (n.d.). Doctor & other health care provider services. Retrieved from https://www.medicare.gov/coverage/doctor-other-health-care-provider-services