How To Pay for Doctor Services under Medicare

If you want Medicare to pay for your doctor bills – as most do – then you must enroll in Medicare Part B. You should be automatically enrolled in Part B if you are age 65 and you have applied for Social Security benefits. Premiums are normally deducted from your Social Security check.

Enrollment is voluntary – you can withdraw at any time. But if you reenroll at a later date you will have to pay higher premiums.

Participating Versus Nonparticipating Doctors

For Medicare purposes, there are three basic kinds of doctors: Participating, non-participating, and opt-out. Participating doctors are doctors who accept Medicare patients and who always take assignments. Non-participating doctors are doctors who do not always take Medicare assignments. Opt-out doctors are doctors who operate fully outside of Medicare. Each category is handled differently for Medicare Part B beneficiaries. Knowing the difference is critical if you want to ensure Medicare will pay for their services.

Participating Doctors

If you are seeing a participating doctor, you will normally need to pay a 20 percent co-insurance, but your doctor will bill Medicare for the rest. Medicare will process the claim and send the money directly to your doctor. The doctor agrees to charge you only the deductible and 20 percent co-insurance amount.

Non-participating Doctors

If you are seeing a non-participating doctor, you must normally pay the full cost of care that you receive. Your doctor must invoice Medicare, and then Medicare will reimburse you 80 percent of the charge, up to the maximum Medicare guidelines for the services received.

In some cases you may pay a limiting charge of up to 15 percent for seeing a non-participating doctor. This is on top of the 20 percent coinsurance you normally pay. So all told you could possibly be responsible for up to 35 percent of the total charge. The allowable limiting charges vary by state.

The limiting charge only applies to certain services and does not apply to certain supplies and durable medical equipment.

In some instances, you will have to submit your own paperwork in order to get Medicare to reimburse you. You can download Form CMS 1490S to start your claim process.

Note: These doctors cannot charge you for submitting a claim. If they do, you can call Medicare officials at 1-800-MEDICARE.

Opt-out Doctors 

If your doctor has opted out of Medicare entirely, it means they simply don’t accept Medicare. In these cases, you will be responsible for the entire payment. These doctors won’t be submitting any invoices to Medicaid, and they are not limited as to how much they can charge.

There are exceptions, in the case of medical emergencies.

Part B Premiums

You must pay a premium to be enrolled in Medicare Part B. For 2016, the Part B standard premium is $121.80 per month. However, you may be required to pay a higher amount if your income is higher. If you file a single tax return and your income is above $85,000 up to $107,000, or your joint income is between $170.000 and $214,000, you will have to pay $170.50 per month.

The costs increase gradually until they are capped at $389.80 per month for single individuals with incomes above $214,000, or joint incomes above $428,000.

You must also be enrolled in Part A and Part B in order to enroll in a Medicare Supplement (Medigap) insurance plan or a Medicare Advantage Plan under Part C.


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