Insurance Company Provider Information
If an individual has a privately administered Medicare service, they should ask their insurance provider about local doctors who accept payments from this coverage.
Usually, insurance companies have a limited network of doctors, hospitals, and healthcare services that accept their payments.
Find your insurance companys customer service phone number or website in your enrollment documents or search for them online.
Which Path You Take Will Determine How You Get Your Medical Care And How Much It Costs
by Dena Bunis, AARP, Updated October 12, 2021
En español | As you think about how Medicare will cover your health care needs, your first major decision should be whether you want to enroll in federally run original Medicare or select a Medicare Advantage plan, the private insurance alternative.
Think of it as choosing between ordering the prix fixe meal at a restaurant, where the courses are already selected for you, or going to the buffet , where you must decide for yourself what you want.
If you elect to go with original Medicare, your buffet will include Part A , Part B and Part D . If you decide to go with Part C, a Medicare Advantage plan, it will be more like a set menu, since a private insurer has already bundled together parts A and B and almost always D into one comprehensive plan.
Need Help With Medicare?
Some aspects of your care will be constant whichever plan you choose. Under both choices, any preexisting conditions you have will be covered and you’ll also be able to get coverage for prescription drugs.
But there are significant differences in the way you’ll use Medicare depending on whether you pick original or Advantage. Here’s a comparison of how each works.
Do All Doctor Accept Medicare Supplement Plans
Having a Medicare Supplement plan gives you access to every doctor in America that accepts Medicare. You may occasionally get someone behind the desk that tries to tell you they dont take your plan however, this is because they have network lists regarding Medicare Advantage Plans. Simply ask if they accept Medicare and if they do they must accept the supplement plan.
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What If A Doctor Refuses My Medicare Card
If youre having billing issues, relax and make sure youre using the right card. The card you need to use will depend on your plan and the care youre seeking. If you have supplementary coverage, you may need more than one card.
Medicare cards are generally just used to verify your eligibility and billing information. You may not need to provide them after you visit a doctor for the first time.
If your card is faded from use, you can replace your card by:
- Logging into your Social Security account at ssa.gov,
Who Is Eligible For Medicare
depends on factors such as:
- Age: You must be 65 years or older to enroll in a Medicare plan. You can receive Part A without a premium if you are receiving or eligible to receive benefits from Social Security or the Railroad Retirement Board. In addition, you can qualify for a premium-free Part A, if you or your spouse had Medicare-covered government employment.
- Disability: If you are under 65 years old and have a disability, you qualify for Medicare.
- End Stage Renal Disease: With this disease, you are experiencing permanent kidney failure and require dialysis or a transplant. You qualify for Medicare.
If you have not been paying for Medicare taxes while you worked, are older than 65 and are a citizen or permanent resident of the U.S., you may have to purchase Part A.
If you are younger than 65, you can receive Part A without a premium if:
- You have been granted Social Security or Railroad Retirement Board disability benefits for at least 24 months.
- You are a patient that requires a kidney transplant or dialysis.
Most people do not have to pay for Part A. However, if you desire Part B, you must pay for it. The premium is deducted monthly from your Social Security, Railroad Retirement or Civil Service Retirement check. If you do not receive these types of payments, you will receive a bill every 3 months from Medicare.
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Using Medicare Advantage Or Medicare Part D In Another State
Medicare Advantage and Medicare Part D prescription drug plans are both sold by private insurance companies.
Medicare Advantage plans can come in a few different forms that can determine how the plan may be used in another state.
Two popular types of Medicare Advantage plans include:
- Health Maintenance Organization plansHealth Maintenance Organization plans feature a network of providers who participate in the plan. These networks can be local or regional, so they can span multiple states in some cases. In order to use the plans benefits, you must visit one of these participating providers. Be sure to check with your plan to ensure you can use your Medicare Advantage HMO plan in another state.
- Preferred Provider Organization plansPreferred Provider Organization plans also feature a network of participating providers, but they typically have fewer restrictions than HMO plans on which providers you may see. You may pay more to receive care outside of your Medicare Advantage PPO network.Also be sure to check with your plan provider to ensure you can use your Medicare plan in another state.
Many Medicare Part D plans may feature a network of pharmacies. Some plans include regional or national networks, while other plans may have more localized networks.
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Tips For Medicare Advantage And Moving To Another State
Advantage plans have doctor networks these networks may vary from county to county. Since policies vary by county, moving will likely result in a necessary plan change.
If you have a Part C plan, upon moving, you can elect to go back to Original Medicare, or you may be able to enroll in a Medigap plan. Although, if you wish to select a new Part C plan, thats an option.
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Services Medicare Doesnt Cover
- Most long-term care. Medicare only pays for medically necessary care provided in a nursing home.
- Custodial care, if its the only kind of care you need. Custodial care can include help with walking, getting in and out of bed, dressing, bathing, toileting, shopping, eating, and taking medicine.
- More than 100 days of skilled nursing home care during a benefit period following a hospital stay. The Medicare Part A benefit period begins the first day you receive a Medicare-covered service and ends when you have been out of the hospital or a skilled nursing home for 60 days in a row.
- Homemaker services.
- Most dental care and dentures.
- Health care while traveling outside the United States, except under limited circumstances.
- Cosmetic surgery and routine foot care.
- Routine eye care, eyeglasses , and hearing aids.
You Can See Any Provider
With our Medicare Supplement you have the freedom to use any doctor in the United States who has not opted out of Medicare. There is no provider network.
Our Medicare Supplement includes free, unlimited coverage for Care My Way®. When you have a health care question, call our 24-hour Nurse Line at 1-800-549-3174. For many common health ailments, you can talk to a Care My Way nurse practitioner who will verify your symptoms and, if needed, call a prescription into your pharmacy, saving you time by avoiding a provider office visit.
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When Should I Use My Medicare Prescription Drug Card
If you have a stand-alone Part D prescription drug plan, youll use the card from that Part D insurer at your pharmacy. Medicare Advantage enrollees with embedded prescription drug coverage can use their Medicare Advantage card to fill prescriptions. All Part D plans have pharmacy networks, and your co-pays will be different depending on if you use a preferred or non-preferred pharmacy. You can use the Medicare plan finder or call your Part D plan to see if you can pay less by filling your medications at a different pharmacy.
Part D insurers will only pay for medications from out-of-network pharmacies in an emergency. You will likely have to pay the difference between your insurers usual and customary rates and the out-of-network pharmacys charges.
If Youre Transitioning Into Or Out Of Inpatient Care
If youve been hospitalized as an inpatient and move out of state after discharge, your Medicare benefits wont be disrupted.
Hospitalization and inpatient care are covered under Medicare Part A, which is part of original Medicare and required to be a part of every Medicare Advantage plan.
While you may still need to switch your Medicare Advantage plan once you move, your Medicare Part A benefits will be covered either way.
Using Original Medicare In Another State
You dont have to do anything to use Original Medicare in another state. You will want to update the address that Social Security has on file for you.
You can use your Original Medicare benefits in another state if you visit any health care provider who participates in the program.
Medicare participation in any state can be broken down into three categories:
How Much Does Medicare Pay For A Doctor Visit
Everyone with Medicare is entitled to a yearly wellness visit that has no charge and is not subject to a deductible.
Beyond that, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. The individual must pay 20% to the doctor or service provider as coinsurance.
The Part B deductible also applies, which is $203 in 2021. The deductible is the amount of money that a person pays out of pocket before the insurance begins to cover the costs.
A person will also need to pay a premium to keep the policy. The standard monthly premium in 2021 is $148.50.
If a person did not sign up when they were eligible at the age of 65 years, they might also need to pay a late enrollment penalty. This penalty can increase the premiums by 10% for each year that someone qualified for Medicare but did not enroll.
The costs associated with Medicare Advantage Plans vary depending on several factors, including:
- whether the plan has a premium
- whether the plan pays the Medicare Part B premium
- the yearly deductible, copayment, or coinsurance
- the annual limit on out-of-pocket expenses
- the type of healthcare services a person needs
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What About Submitting Claims For Reimbursement
Its true, many PPO plans allow you to pay for your services and then submit a receipt for reimbursement.
But if the provider wont treat you, you cant even submit a claim to your insurance company for reimbursement.
So this doesnt help you at all.
And if they did agree to treat you, would you really want to pay the bill yourself. File paperwork to an insurance company and wait for them to reimburse you?
How long is it going to take to get reimbursed? I dont know that answer, do you?
Also whats the process for getting reimbursed? Well heres something else buried deep in an evidence of coverage document:
If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.
Thats right, if you did not follow all the rules, we will not pay for our share of the cost.
What are the rules? Do you know them all?
Do I Have To Change Medicare Doctors If Mine Isnt In My Provider Network
As long as your current doctor accepts Medicare, you should be able to see them and receive coverage for the visit. However, if they decide not to accept Medicare or stop participating in the program, you will need to find another doctor.
If youre joining a Medicare Advantage plan, you can contact the insurance company directly to find out if your preferred doctor is covered in the network. If not, you can either choose a new doctor or a new insurance provider.
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Can I Use Medicare Everywhere In The Us
Medicare is widely accepted across the U.S., but its not universal. Original Medicare provides nationwide coverage, whereas Medicare Advantage plans have provider networks that can be limited to a local area. When reviewing plan options from private health insurers, pay close attention to which providers in your area accept Medicare to ensure that you have access to care when you need it.
Don’t Give Personal Information To Plan Callers
Medicare plans aren’t allowed to call you to enroll you in a plan, unless you specifically ask to be called. Also, plans should never ask you for financial information, including credit card or bank account numbers, over the phone.
No one should call you without your permission or come to your home uninvited to sell Medicare products. Call 1-800-MEDICARE to report a plan that does this. Learn more about how to prevent Medicare fraud and abuse.
Before enrolling in any Medicare Advantage health plan, you can confirm that your Atrium Health doctor is participating in the plan. You can do this by:
- Visiting Medicare Plan Finder to help you understand the Medicare Advantage health plan options in your county, as well as see which doctors and hospitals are in-network.
If youre happy with your existing Medicare coverage, theres no need to do anything during Medicare Open Enrollment. But its always good to check that your current plan is still available and that you can continue to see your preferred doctors and hospitals.
You can continue to see your preferred doctor until your new coverage begins.
Providers Non In The Network Not Required To Treat You
Here is an excerpt from one company that touts your ability to go to any provider you want with their PPO Advantage plan:
As a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations.
Thats right. It says no obligation to treat you, except in emergency situations.
Can You Have Medicare And Dual Residency
You can have Medicare while living in two states, but youll choose one location as your primary residence. There will be some Medicare plans that benefit you more than others when you have multiple homes.
Some retired people choose to reside in two different locations. An example is living in New York for half the year and staying in Florida for the colder half.
The last thing you want to worry about when enjoying the snowbird lifestyle is whether your health coverage is comprehensive. So, well walk you through what you need to know about Medicare while living in more than one state.
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What Else Do I Need To Know About Original Medicare
- You generally pay a set amount for your health care before Medicare pays its share. Then, Medicare pays its share, and you pay your share for covered services and supplies. There’s no yearly limit for what you pay out-of-pocket.
- You usually pay a monthly premium for Part B.
- You generally don’t need to file Medicare claims. The law requires providers and suppliers to file your claims for the covered services and supplies you get. Providers include doctors, hospitals, skilled nursing facilities, and home health agencies.
Can I See A Doctor In Another State With Medicare
With Original Medicare , you can see doctors anywhere in the United States, as long as they accept Medicare.
If you travel or move to another state, your Original Medicare coverage goes with you. The same is true if you move to or travel to Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands.
If you have a Medicare Supplement Insurance plan , a Medicare Advantage plan or a Medicare Part D prescription drug plan, this guide can help explain what you need to do to use your Medicare plan in another state.
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Not Sure What Type Of Provider You Need
Use our provider search tool to find quality data, services offered, and other information for these type of providers:
Get detailed information about every Medicare-certified nursing home in the country. A nursing home is a place for people who cant be cared for at home and need 24-hour nursing care. Find nursing homes by location and compare the quality of care they give.
Find and compare hospitals that offer services like medical, surgical, and psychiatric care. Use the Hospital type” filter to find special facilities, like acute care, critical access, childrens hospitals, and more.
Doctors & clinicians
Find a doctor or clinician that accepts Medicare near you, or compare doctors who are qualified to practice in many specialties.
Home health services
Home health care describes a wide range of health care services that you can be get in your home at less expense than a hospital or skilled nursing facility. Compare home health agencies using the patient survey star ratings or the quality of patient care star rating.
Hospice agencies most often give services where you live, whether you’re at home, an assisted living facility, or a nursing home. Find hospices that serve your area and compare them based on the quality of care they give.
Inpatient rehabilitation facilities
Long-term care hospitals
Medical supplies & equipment