Medicare, the federal health insurance program designed to cover people age 65 and older (and some younger individuals with qualifying disabilities), provides health insurance for many American seniors.
The vast majority of doctors and hospitals accept Medicare, but they’re not required to, and the percentage of those who don’t has been increasing. According to 2023 data from KFF, an independent health policy information resource, 1% of all nonpediatric physicians formally opted out of the Medicare program in 2023.
KFF reports that the percentage of opt-outs varies by specialty; the highest is psychiatrists, at 7.7% not accepting payment from Medicare. Across the board, these figures translate to more than 11,000 physicians who won’t see you if you’re covered by Medicare.
Why Some Doctors Don’t Take Medicare
The biggest reason a provider opts out is money; Medicare typically pays less for services and procedures than private insurers do. Plus, Medicare, which is administered by the Centers for Medicare & Medicaid Services, or CMS, typically pays significantly less than the retail cost of the service.
Medicare can do this because it’s the largest payer for health care services in the United Sates. In 2021, for instance, Medicare made more than $424 billion in payments to more than 1.5 million health care providers, according to CMS. It also covers more than 66 million people, so it has volume on its side.
As the big kid on the block, CMS has a lot of leverage to negotiate prices and effectively compel providers to accept their payment terms. And, for many providers, Medicare revenue is what keeps the doors open.
For some practices and providers, however, Medicare payments haven’t been sustainable, says Adria Goldman Gross, a medical bill advocate with MedWise Insurance Advocacy, a division of MedWise Billing Inc. in Monroe, New York, and coauthor of “Solved! Curing Your Medical Insurance Problems.”
“Either they’re having difficulties receiving payments, or they’re not being reimbursed at reasonable rates,” she explains.
When these providers opt out of the Medicare network, that can be a big problem for some patients.
[Read: 5 Steps for Picking a Medicare Plan.]
7 Options If Your Doctor Stops Accepting Medicare
If your doctor stops accepting your health insurance, these are some of your possible options:
1. Ask for clarification
Ask whether your doctor is dropping all Medicare plans, or just Medicare Advantage, advises Cindy George, a senior personal finance editor at GoodRx, a free website and mobile app that tracks prescription drug prices and provides coupons and discounts on medications.
“Some health care professionals may not accept Medicare Advantage because of the frequency of prior authorization or changes to in-network providers and facilities,” George explains.
These providers, however, may continue to accept original Medicare (Part A and Part B), so you might consider switching plans, she adds.
[Read: Medicare Fall Open Enrollment: What You Need to Know.]
2. Pay out of pocket
If you want to stay with the doctor and you can afford it, you may be able to pay out of pocket for your health care.
Some practices may be willing to enter into a direct primary care (DPC) agreement.
“Under DPC, you typically pay a monthly fee that covers particular services, such as routine screenings, chronic condition management, care coordination and visits for acute issues,” George explains.
With a DPC, however, you have to sign an agreement stating that any services provided will not be billed to your Medicare plan.
“Some doctors, particularly specialists, may not consent to this arrangement,” she adds.
3. Negotiate the fees
If you’d prefer to stay with a certain doctor but the cost is too high, it never hurts to ask if they’d be willing to negotiate.
“Many doctors offer cash-pay discounts or flexible payment plans to help patients remain in their care,” says Lindsay Dymowski Constantino, cofounder and president of Centennial Pharmacy Services and LTC@Home Pharmacy Quality Commission, based in Philadelphia.
You may end up paying more than the Medicare rate but less than the full retail cost.
[Read: What Medicare Doesn’t Cover and How to Manage Costs]
4. Find a new doctor
“If a direct payment isn’t feasible, it’s important to find a new provider as soon as possible to avoid any gaps in your care,” Dymowski Constantino says.
The CMS Medicare Physician Compare tool lets you look at doctors side by side so you can make an informed selection.
“The Medicare website is a helpful resource for locating providers in your area who accept new patients and participate in your plan,” Dymowski Constantino adds. “Some health care facilities specialize in serving Medicare beneficiaries and may have more experience and resources dedicated to handling the unique needs of Medicare patients.”
5. Request a referral
If your provider stops accepting Medicare, they may be able to recommend another local provider who still accepts it.
“It’s also a good idea to talk to family members or friends who are Medicare beneficiaries to see if they have recommendations,” Dymowski Constantino says.
Some health care networks and senior service organizations also offer resources to help Medicare patients connect with high-quality providers.
6. Talk to your pharmacist
“Pharmacies can be an anchor in your care, especially when other parts of your health care team change,” Dymowski Constantino says.
Not only might your pharmacist be able to make a recommendation for a good local health care provider who accepts Medicare, but they can also help maintain some elements of care during your transition.
“If you find yourself without a doctor or if you experience delays in establishing care with a new one, notify your pharmacy right away,” Dymowski Constantino adds. “A trusted pharmacy can provide support by coordinating with your historic providers for ongoing refills or helping connect you with community health resources.”
These efforts can help you avoid missed medications or lapses in care while you navigate your next steps.
7. Seek other sources of care
Depending on your need, you may be able to visit an urgent care center, as most of them accept Medicare. This can be a good option for certain nonemergency, short-term issues, such as a cold, stitches or minor wound care, sprains and strains or routine vaccinations.
For more emergent or larger issues, you may need to visit an emergency room.
But relying on these alternative types of care long-term or for chronic conditions is not cost effective and does not provide the continuity of care you’d get from a primary care provider.
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What to Do If Your Doctor Stops Accepting Medicare originally appeared on usnews.com
