Medicare Q&A: What’s an ‘opt-out’ doctor?
Posted on May 29, 2014 by bob in Medicare
Dear Marci,
My doctor told me that he is now an opt-out doctor. What is an opt-out doctor? — Shelley
Dear Shelley,
An opt-out doctor has formally “opted out” of the Medicare program. Opt-out doctors do not submit medical claims to Medicare and are not subject to the Medicare law that limits the amount they may charge patients with Medicare. In other words, opt-out doctors can charge whatever they want for health care services they provide to patients with Medicare.
If you have Original Medicare, the traditional Medicare program administered directly through the federal government, it’s generally best to avoid seeing opt-out doctors. When you see a doctor who has opted out of Medicare, you are responsible for the entire cost of your care. Medicare will not pay for care you receive from an opt-out doctor. While there may be a few exceptions in the case of emergencies, you are generally responsible for the full cost of the care you receive from opt-out doctors.
If you have Original Medicare, try to see a doctor who accepts Medicare and takes assignment to get your care at the lowest cost. Health care providers who take assignment accept the Medicare-approved amount for health care services as full payment.
If you have Original Medicare and see an opt-out doctor, keep in mind that the doctor should have you sign a private contract that states you understand you are responsible for the full cost of services you receive. If the opt-out doctor does not give you this contract before providing you with care, you are not responsible for paying for that care. Keep in mind that psychiatrists have been more likely to opt out of Medicare in recent years, compared to other doctors. Be sure to ask your doctor if he/she accepts Medicare before you begin to receive health care services.
If you have a Medicare Advantage plan, also known as a Medicare private health plan, you will most likely need to get health care services from in-network doctors. Contact your plan directly to learn more about which types of doctors you can see for covered care.
Before you see any type of doctor, ask your doctor what types of insurances he/she accepts so you can get a sense of whether the health care services you receive will be covered.
Dear Marci,
Does Medicare pay for ambulance services? — Janette
Dear Janette,
Yes, Medicare can cover emergency and non-emergency ambulance services if the following requirements are met:
n Ambulance transport is medically necessary, meaning that an ambulance is the only safe way to transport you, and the reason for your trip is to receive a service or return from a Medicare-covered service you need;
— You are transported to and from certain locations; and
— The ambulance carrier or supplier meets Medicare ambulance requirements.
Keep in mind Medicare defines an emergency as a situation in which your health is in serious danger and every second counts to prevent your health from getting worse. Medicare may cover non-emergency ambulance services under limited circumstances. However, keep in mind that lack of access to alternative transportation alone will not justify Medicare coverage.
Specifically, Medicare may cover non-emergency ambulance services if you are confined to your bed, meaning you are unable to get up from a bed without help, unable to walk or unable to sit in a chair. Medicare may also cover non-emergency ambulance services if you need vital medical services during your trip that are only available in an ambulance. An example of this includes monitoring of vital functions.
If you have Original Medicare, the traditional Medicare program administered directly through the federal government, Medicare will pay 80 percent of its approved amount for Medicare-covered ambulance services.
You or your supplemental insurance will be responsible for the remaining 20 percent coinsurance. If you have a Medicare Advantage plan, also known as a Medicare private health plan, contact your plan directly to learn how your plan covers ambulance services.
Lastly, know that Medicare will never pay for ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation for people with disabilities.
Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare.
