Saturday, April 6, 2024

Do I Need A Primary Care Physician With Medicare

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When A Doctor No Longer Accepts Medicare Patients Left Holding The Bag

Why do I need a primary care doctor?

Pneumonia. Heart problems. High cholesterol. Betsy Carrier, 71, and her husband, Don Resnikoff, 79, relied on their primary care doctor in Montgomery County, Maryland, for help managing their ailments.

But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couples insurer.

Its a serious loss, Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physicians retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesnt reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay a fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician.

The exact number of physicians with concierge practices is unknown, health care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

The move to concierge medicine may be more prevalent in wealthier areas.

Carmen Heredia Rodriguez: ,

Does Medicare Cover A Primary Care Physician Near Me

If you have Original Medicare , Medicare Part B generally covers medically necessary services and tests you get in a doctor office including visits to your primary care physician. You generally pay 20% of the Medicare approved amount, except for certain preventive services. Because this amount is a coinsurance you wont know the actual costs until you receive the bill.

If you have Medicare Advantage, you may pay a copayment for a primary care doctor visit. A copayment is a set dollar amount, for example $10, that you pay for an office visit for a primary care doctor. A benefit of Medicare Advantage is knowing in advance what you will typically pay for a doctor visit.

The Cares Act Of 2020

On March 27, 2020, President Trump signed a $2 trillion coronavirus emergency stimulus package, called the CARES Act, into law. It expanded Medicare’s ability to cover treatment and services for those affected by COVID-19. The CARES Act also:

  • Increases flexibility for Medicare to cover telehealth services.
  • Increases Medicare payments for COVID-19ârelated hospital stays and durable medical equipment.

For Medicaid, the CARES Act clarifies that non-expansion states can use the Medicaid program to cover COVID-19ârelated services for uninsured adults who would have qualified for Medicaid if the state had chosen to expand. Other populations with limited Medicaid coverage are also eligible for coverage under this state option.

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How Can I Get Help Finding A Plan That Covers My Primary Care Doctor

Now that you have a better understanding of why its so important to find a primary care doctor, you might have questions on how to find coverage that helps lower your medical costs. Or, you may have a primary care doctor you love but would like to switch plans. If youd like help making sure your new plan includes your PCP, we can help.

eHealths team of trusted and expert licensed insurance agents can go over your options to help you find coverage that may work for you. Enter your zip code where requested on this page to see personalized individual and family health plans, or browse health insurance plans by state. As always, you can call the number on this page to speak with someone directly.

Find A Good Local Doctor

How to Change My Primary Care Physician on Medicare ...

Is the practice youre considering near where you live? Convenience is important to most adults 65+ especially when youre sick, need to be seen urgently, or dont drive. Having a practice thats in or close to your hometown is an important factor for your care.

Does the practice offer assistance if you need help getting there? At Iora, we provide transportation to patients that need help getting to appointments.

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What Do Primary Care Physicians Treat

Because of the nature of their health care practice, primary care doctors that accept Medicaid and Medicare can treat a wide variety of illnesses, chronic conditions, and injuries.

The number one reason people go to the doctor without an appointment is to examine a sudden injury or illness. Your primary care physician might perform the following:

  • Diagnostic tests
  • Sexually transmitted infections
  • Signs of domestic violence

Rates for primary care doctors that accept Medicare vary by state and doctor, but you can expect Medicare to cover most of them.

If you have a chronic condition, youll probably need to see a specialist, but a primary care physician can still help you manage your condition with the following services:

  • Creating lifestyle plans for diet and exercise
  • Management of prescription medication
  • Performing diagnostic exams

Doctors work closely with specialists to ensure you get the best care possible, and many affordable primary care doctors that accept Medicare can also evaluate your need for a specialist.

Do Doctors Have To Accept Medicare

Doctors arent required to accept Medicare in order to practice medicine. That said, its rare to find a medical provider who hasnt been registered with the Medicare program at some time.

All practicing doctors must register with the Centers for Medicare and Medicaid Services regardless of their Medicare enrollment status, so your doctor will have had some contact with the Medicare program.

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Does Medicare Require Referrals

Often insurance companies require you to have a referral, which is a written order from your primary care doctor, before theyll pay for a specialists care.

While Medicare doesnt require referrals as a general rule, certain situations may require a specific order from your primary care provider.

Original Medicare doesnt require referrals for specialist care. However, if you have Part A or Part B coverage through a Medicare Advantage plan, you may need a referral before seeing a specialist.

Here are the referral requirements for each section of Medicare:

  • Medicare Part A. Part A is the portion of Medicare that covers hospitalization and inpatient costs and treatments. When you have Medicare Part A as part of original Medicare and not through a Medicare Advantage plan, no referrals are required for specialist care.
  • Medicare Part B.Part B is the outpatient portion of Medicare. When Part B is part of original Medicare, you arent required to get a referral from your primary care doctor in order to see a specialist.
  • Medicare Part C .Advantage plans are offered by private insurance companies, and they cover both the inpatient and outpatient costs of Medicare parts A and B, plus other optional services. While these plans are meant to give you more choice in your medical care, they often come with more restrictions as well. Several types of Medicare Advantage plans require referrals for specialist care or certain other services.

How Do You Find A Primary Care Physician

How to Switch Your Primary Care Doctor with a Medicare Advantage Plan

Choosing a doctor can be challenging. You might not want to just pick a name out of the phone book. If your insurance plan requires you to choose a PCP, however, you may want to take time to research your options. Here are some ideas to get you started:

  • Your health insurance plan. Your health insurance plan may keep an online list of network primary care doctors who are accepting new patients. Choosing a PCP is often the first step in seeking treatment under an HMO plan. PCPs will handle any referrals to specialists you need.
  • Personal referrals. People often ask their friends, families, and co-workers for referrals to primary care physicians. If someone you respect and trust has a positive experience with a doctor, its possible you may like that particular physician.
  • Referrals from your current physician. If you are moving to a new area, you could ask your current physician to help you find a PCP in your new neighborhood, assuming youre still going to be covered under the same health insurance plan.
  • Hospital access. It is common for hospitals to offer a referral service that can provide you with the names of staff doctors who meet certain criteria you may be seeking, such as specialty, gender, experience, and location.

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Federally Qualified Health Centers

A federally qualified health center is a community clinic that sees everyone. They accept Medicare and Medicaid and some kinds of insurance. If you dont have insurance, payment is on a sliding scale based on your income. There are FQHCs in cities and in rural areas, and each one serves the needs of that community.

What Is A Primary Care Physician

A primary care doctor , is a doctor that practices general medicine. PCPs help with your health including preventative care, routine physicals and screenings, annual shots, diagnosing and managing chronic conditions, and general minor illnesses or injuries.

There are five different kinds of primary care doctors, each with a different background and area of focus.

  • Family medicine doctor: Doctors that can provide health care for your whole family and act as one-stop-resource for treating a variety of needs and services for babies, children and adults.
  • Internal medicine doctor: Doctors that care for adults only and focus on treating issues that primarily affect adults such as high blood pressure.
  • Internal medicine-pediatrics doctor: Dual certified in both internal medicine and pediatrics, these physicians can care for both kids and adults and help with balancing regular preventative care needs with specialized care needs.
  • Pediatrician: Physicians that specialize in child health care from birth through early adulthood and are experts in developmental milestones, routine care, and treating minor illnesses and injuries.
  • OB-GYN : Experts in womens health that help with family planning, pregnancy, menopause, and preventative screenings like mammograms and Pap smears.

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Finding A Medicare Primary Care Doctor Near Me

You can use Medicares physician compare tool to find a primary care physician near you. Just type in your city and state and the term primary care. You will get results for doctors that are categorized as family practice, general practice internal medicine and geriatric medicine. Any one of these doctors may be able to be your primary care physician.

What If You See A Doctor Who Doesnt Accept Medicare

5 Reasons Why You Need a Primary Care Physician

Youre always allowed to obtain care outside of the Medicare system if you prefer.

  • If youre seeking a treatment that Medicare covers from a doctor who doesnt accept Medicare: Your medical provider needs to show the federal government that theyre not taking advantage of you. Your doctor will give you a contract to sign on that contract, itll state that you understand your doctor wont be paid by Medicare. In other words: you will be responsible for the full bill. The contract will have to be re-signed every two years if you keep receiving treatment.
  • If youre seeking a medical service that isnt a part of your Medicare coverage: For instance, if youre meeting with an audiologist to test your hearing and get a hearing aid, then you wont have to sign a special contract. You will have to make payment arrangements on your own to cover the full cost of the medical service.

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When Should I Use My Medigap Card

People with Original Medicare can purchase supplemental coverage through Medigap. Coverage varies across the 10 federally standardized plans, but they all cover some portion of Medicare beneficiaries Part B cost sharing as well as the cost of hospitalization under Part A. If you visit the doctor or are hospitalized, both your Medigap card and your Original Medicare card will be needed to process your bills. Even though Original Medicare often will automatically send claims to your Medigap insurer, your health care provider will need to see your Medigap card in case this doesnt happen or there are other billing issues.

How Do I Find A Doctor That Accepts Medicare

If you want to find a doctor who accepts Medicare, you may visit prospective physicians websites, and theyll list the insurers they accept as well as if they participate in Medicare assignment. You can also call the office, and theyll provide you with information about the insurance providers they accept. You may also want to use a search engine and inquire about what physicians in your area accept Medicare assignment by searching, Doctors in Reseda, CA Who Accept Medicare assignment.

Dr. Rachman is one practitioner who takes Medicare and Medicare assignment. He has around 20 years of experience taking care of patients. He focuses on internal medicine and helps patients who have diabetes and hypertension while also offering primary care services to those with Medicare.

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What Services Does Medicare Cover

Medicare Part A covers hospice care, home health care, hospital inpatient care, surgery, skilled nursing facility care, and lab tests. Medicare Part B covers doctor visits, lab tests and X-rays, preventive services, mental health services, and durable medical equipment. Medicare coverage for many items, tests, and services depends on your location.

Will All Doctors Who Take Medicare Cost The Same Amount

CMS Physician Compare Patient Story

Not all Medicare doctors charge the same amount for certain medical costs. When a doctor accepts assignment, theyve agreed to provide a service at the price Medicare has determined is fair. These par-ticipating doctors are called PAR providers. If your doctor regularly sees Medicare patients, then they probably accept the assignment. But ask before youre treated.

If your doctor doesnt accept assignment:

  • They may ask for payment at once, and,
  • Youll have to pay up to an additional 15% of the Medicare rate out-of-pocket, in addition to your existing copayment .

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Importance Of A Primary Care Doctor

Video transcript

When it comes to your health journey, it feels good to know you’ve got support every step of the way.


Thats where your primary care doctor comes in.

Your doctor knows you best and understands your health history and health goals. This is who you turn to first for everything from routine care to prescriptions and more.

ON-SCREEN TEXT: [Preventive care



Your doctor also provides you with preventive care, such as well-child visits, annual checkups, mammogram screenings and immunizations.


And, since most doctors offer virtual visits for primary care, you can choose to see them in person or from home.


So, whether or not your plan requires you to have a primary care doctor, its a good idea to choose one.


And a tip? Be sure to choose one whos in your network

ON-SCREEN TEXT: [Out-of-network

because staying in network can help save you money.


For example, when you see a network doctor for preventive care, the visit is covered by most health plans at no additional cost.


Now that you know the benefits of having a network doctor, lets look at how to find the one thats right for you.


Specialty Care

Medical Groups]

First, go to uhc dot com slash provider search. Then, choose your health plan name and select primary care.




care that helps meet your needs.

Why Do I Need To Find A Primary Care Doctor In My Plans Network

If youre enrolled in an HMO plan, youll need to find a primary care physician that is in network. Using network doctors is important because:

  • Your costs may be higher otherwise. In some cases, using an out-of-network doctor may mean paying higher medical costs or even paying the full cost for care. PPO plans are different, where your costs may be higher with non-network doctors. With an HMO, you may have to pay the entire bill if you use an out-of-network PCP.
  • Your plan may not cover you. Most HMO plans make an exception and will cover non-network doctors for urgent or emergency care. However, when it comes to your primary care doctor, youll generally need to stay in network to be covered. Check your plans rules for more information.

As mentioned, every health plan should have a list of network providers. If youre searching for a PCP, contact your health plan to make sure your doctor is covered. Or, if you have questions on whether an HMO or PPO plan might be better for your needs, an eHealth licensed insurance agent can explain the differences and work out what might be right for you.

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It May Cover Major Or Recurring Medical Expenses

If you are on Medicare but opt to use DPC, you will still receive medical savings through your insurance. Medicare will still cover most of your prescriptions or other medications your DPC provider prescribes to you.

Keeping Medicare is also wise for patients using direct primary care to avoid liability for major medical services, such as hospital charges, surgeries, physical therapy, or if the patient needs to see a specialist.

If You Have Medicare Supplement

Why Do I Need a Primary Care Physician?

Supplemental insurance covers the cost of your care after Medicare has paid its share. Your doctor must arrange payments with Medicare and Medicare Supplement. They cant decline one and accept the other.

A doctor who accepts Medicare will be paid via Original Medicare. Your Medicare Supplement coverage will kick in afterwards. It wont replace that Medicare payment.

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