One of the most common questions we get regarding Medicare Supplements (MediGap) is what providers can be accessed for care. Many assume that a Medicare Supplement from Blue Shield or Anthem Blue Cross requires using their respective doctor networks. In fact, Medicare Supplements don’t have their own provider network; you can see any Medicare contracted provider. It is the relationship between the provider and Medicare that is key and important to understand.
There are three different possible relationships a provider can have with Medicare, and they can directly impact what you pay for medical services. These relationships are called: Participating, Non-Participating, and Opt-Out providers.
A Participating provider is contracted with Medicare and has agreed to accept Medicare’s fee schedule (also known as “accepting assignment”) as payment in full for all Medicare covered services. They cannot charge more than assignment and patients would only be responsible for deductibles and coinsurance amounts. These providers must submit claims to Medicare for the patient and typically wait for Medicare to pay its share before billing the patient.
Non-Participating providers are also contracted with Medicare but do not accept Medicare assignment and may charge up to 15% above assignment (called excess charges) for services, but no more. They may ask for the full payment at the time of service and are not required to submit claims for patients.
Providers who have “opted out” have chosen not to work with Medicare. They cannot bill Medicare and Medicare will not pay for services (except for emergencies). Patients should be prepared to pay 100% of the bill. Providers who opt out do so for a minimum of two years at which point they can choose to remain as an “opt out” provider, contract with Medicare as a participating provider or as a non-participating provider.
For those of you with Medicare Supplement Plan F or Plan G, be reassured that in addition to deductibles and co-insurance, excess charges from Non-Participating Providers is covered in full. However, Medicare Supplements will not pay if Medicare does not pay first. Therefore, when seeing a provider that has opted out of Medicare, the Medicare Supplement will not pay benefits either.
Providers are required to tell you prior to receiving services, what relationship they have with Medicare. I hope this article helps in understanding how that may affect you.
All the best in the New Year,
Phil
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