Q: My doctor has started charging an additional fee on top of what she used to charge, and Medicare isn’t covering it. Why is this?
A: It sounds as though your doctor has stopped participating with Medicare. This means that, while she still accepts patients with Medicare coverage, she no longer is accepting “assignment,” that is, the Medicare-approved amount.
As an example, let’s say the Medicare-approved amount for a check-up is $100, but the doctor does not accept assignment and charges an additional 15 percent (this percentage above the Medicare-approved amount is typically limited to a certain percentage). So, the visit will cost $115. Medicare will pay their 80 percent (of the Medicare-approved amount), assuming the Part B deductible has already been met, so in this case, $80.
The patient then pays the remaining $20 of the approved amount, but then also the $15 in “excess” charges, for a total of $35.
A Medicare Supplement, or Medigap, plan might cover both the remaining 20 percent and the $15 in excess charges. However, several Medigap plans don’t cover Medicare Part B excess charges.
It’s important, therefore, to not only verify with your physician(s) that they accept assignment, but also, if you have supplemental coverage, to understand what is covered by your plan.
Q: Our doctors want us to sign a special contract for our care because they aren’t going to accept Medicare any longer. Can they do this?
A: Yes, physicians and other health care providers can “opt-out” of Medicare. You can still see these providers, but they must enter into a private contract with you (unless you’re in need of emergency or urgently needed care).
This is a written agreement between you and the provider regarding payment for services. You don’t have to sign such an agreement and there are Medicare rules pertaining to these agreements.
Oftentimes, it’s simpler to switch providers to one who still gives services through Medicare. If you choose to sign a private contract with your doctor, know these rules apply:
Medicare won’t pay any amount for the services you get from this doctor or provider, even if it’s a Medicare-covered service.
You’ll have to pay the full amount of whatever this provider charges you for the services you get. You and your provider will set up your own payment terms through the contract.
If you have a Medicare Supplement Insurance (Medigap) policy, it won’t pay anything for the services you get. Call your insurance company before you get the service if you have questions.
Your provider must tell you if Medicare would pay for the service if you got it from another provider who accepts Medicare.
Your provider must tell you if he or she has been excluded from Medicare.
You cannot be asked to sign a private contract for emergency or urgent care.
You are always allowed to get services not covered by Medicare if you choose to pay for a service yourself.
The Michigan Medicare and Medicaid Assistance Program (MMAP) can help if you have questions about navigating these health systems or would like to attend one of our free classes. Call Mistelle Sleigh at (269) 408-4354 or email her at mistellesleigh@areaagencyonaging.org.