Reinking: What To Look For In A Medicare Provider

If you have Original Medicare, your costs for outpatient care can vary depending on the type of provider you see. For cost purposes, there are three types of providers, meaning three different relationships a provider can have with Medicare.

A provider's relationship with Medicare determines how much you will pay for Part B-covered services. The word provider often refers to a doctor or physician, but it can also refer to other providers of care, such as a hospital, dialysis facility, home health agency, or durable medical equipment (DME) supplier, among others.

A participating provider accepts Medicare and always takes assignment. Taking assignment means that the provider accepts Medicare's approved amount for health care services as full payment. To pay the least for services, see a participating provider when possible.

These providers are required to submit a bill (file a claim) to Medicare for care you receive from them. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are steps you can take to help resolve the problem.

If you see a participating provider, you are responsible for paying a 20% coinsurance for most Medicare-covered services.

Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.

A non-participating provider accepts Medicare but does not agree to take assignment in all cases (but they may take assignment for some services). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare's approved amount for health care services as full payment.

An opt-out provider does not accept Medicare at all and has signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so.

Medicare will not pay for care you receive from an opt-out provider (except in emergencies) and will not reimburse you. You are responsible for the entire cost of your care.

The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not pay.

Opt-out providers do not bill Medicare for services you receive. Keep in mind that many psychiatrists opt out of Medicare.

All Medicare Advantage Plans must cover the same health care services as Original Medicare, but they may do so with different costs and restrictions. For example, some Medicare Advantage plans require you to get prior authorization for certain services, or to get a referral from a primary care physician (PCP) before seeing a specialist.

Each type of Medicare Advantage Plan has different network rules. A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. If a provider you see is part of your planís network, they will be considered an in-network provider. There are various ways a plan may manage your access to specialists or out-of-network providers. Remember that your costs are typically lowest when you use in-network providers and facilities, regardless of your plan.

Your Medicare Advantage Plan is required to cover emergency and urgently needed care anywhere in the U.S. without imposing additional costs or coverage rules (such as prior authorization). This means that if you seek emergency care from an out-of-network provider, your Medicare Advantage Plan must cover the care as if you had gone to an in-network provider.

Medicare Advantage Plans define an emergency by the prudent person standard. Prudent here means acting with care or thought about the future. This standard ensures that even if your condition turns out not to be a medical emergency, it will still be covered as long as a prudent person would have assumed it was an emergency at the time you got care.

It is important to know that not all Medicare Advantage Plans even plans of the same type work the same way. Make sure you understand a plan's network and coverage rules before enrolling. If you have questions, contact your plan for more information.

Jill Reinking, this column's author, works with the Wyoming Insurance Department. Contact the Wyoming Insurance Department by visiting doi.wyo.gov or call 307-777-7401.