Medicare beneficiaries want the ability to choose their physicians and continue seeing them. However, lately, there has been considerable upheaval, causing anxiety for many.
Here is one email question that has popped into my box many times.
“I am new to Medicare and recently enrolled in a Medigap Plan G. When I checked with my physician’s practice, the billing person told me they canceled their contract with [the insurance company sponsoring this plan]. I will need to find new doctors now. So many of my friends are experiencing this, too. What can I do?”
There have been many news stories about Medicare patients needing to change doctors because their health system is no longer contracted with the patients’ Medicare Advantage plans. This situation highlights one very important difference in the type of Medicare coverage a beneficiary has chosen. The two most common options are Medicare Advantage or Original Medicare (Part A and Part B) with a Medigap policy (listed as Medicare Supplement Insurance on the card). Insurance companies can sponsor both Medicare Advantage and Medigap plans. However, different rules apply to each type of coverage.
Medicare Advantage
Medicare Advantage plans are network-based. Just over 60% of those who elected this coverage, often referred to as members, are in health maintenance organization (HMO) plans. Members must see providers in the network for routine (nonemergency) medical care. Other than for true emergency situations, an HMO may not pay for care outside the network.
Preferred provider organization (PPO) plans offer the option to receive services out-of-network, which can provide a degree of flexibility. However, those services can cost considerably more, sometimes 50% of the cost. Most important, if physicians do not have a contract with a plan, they have no obligation to see those patients.
Health systems work under contracts with Medicare Advantage. The contracts spell out many details, including prior authorization rules, payment rates and terms. Since 2022, contract disputes have increased, leading to health systems reducing or dropping their contracts or Medicare Advantage plans cutting off network access for the systems.
When a health system goes out-of-network or no longer has a contract, its patients who have that plan must find a new physician or enroll in a plan that still has that system in-network. Not only does that take time, but it can also present challenges and create anxiety, especially for those who are in the midst of treatment.
Original Medicare with a Medigap Policy
- There are no networks, HMOs or PPOs, with this path. Instead, there are doctors who decided to participate in Medicare and accept assignment. They do not have to see every Medicare patient but, for the ones they see, they must bill Medicare and cannot charge more than Medicare allows. Around 98% of non-pediatric physicians participate in the Medicare program.
- Without network limitations, Original Medicare beneficiaries are able to see any physicians in the U.S. and its territories who accept assignment, listed in the Physician Compare database.
- A doctor who accepts assignment submits a claim to Medicare, not an insurance company. If it meets the necessary criteria for coverage, Medicare can cross that claim over to the Medigap insurer automatically that can pay the doctor directly.
- Physicians who accept assignment must bill any Medigap policy a patient has. The fact that their office no longer has a contract with a Medicare Advantage plan sponsored by that same insurance company is irrelevant. If Medicare pays its portion, the Medigap policy must likewise pay its share, no questions asked.
So, when it comes to which physicians can you see, it is not the name of the insurance company on the card that drives the decision but, rather, the type of coverage. Take time to understand whether you have a Medigap or Medicare Advantage plan and how that plan works.
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