Aren’t Visits to All the Doctors You Want to See Covered by “Original Medicare?”
No, they are not!
Original Medicare – the form of coverage you obtain directly from the government - is made up of two parts: Medicare Part A and Medicare Part B.
Medicare Part A covers hospital-related expenses, such as inpatient hospital care, skilled nursing facility care, hospice care, and home health care.
Medicare Part B covers medical expenses, such as doctor services, outpatient care, preventive care, medical equipment and supplies, ambulance services, and mental health services.
Original Medicare is administered by the federal government and is available to people who are age 65 or older, as well as to younger people with certain disabilities or who have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
It is important to note that Original Medicare does not cover all medical expenses, and there may be out-of-pocket costs and deductibles associated with receiving medical care under this program. To help cover these costs, many people choose to enroll in additional Medicare coverage, such as Medicare Part C (Medicare Advantage) and/or enroll in a Medicare Supplement plan along with a Medicare Part D (prescription drug coverage).
A friend we know recently had an operation to correct a condition known as lateral epicondylitis, also known as tennis elbow. Years ago when he was in college, he actually played tennis. But he needed help now because he was in so much pain.
He was looking for an orthopedic surgeon who could perform an operation known as a lateral epicondyle release, or tennis elbow surgery. This surgery, which is common, relieves the tension in the elbow’s extensor tendon. After the operation, he was hoping to experience less pain in his daily activities. He even thought he might be able to play tennis again.
He called some of his friends and asked if they could recommend any surgeons who could do the operation. One of those friends gave him the name of a top orthopedic surgeon in New York – the kind of surgeon who had pictures of professional athletes displayed in his waiting room. “He’s the tops, the guy you want to fix your elbow,” he added.
So our friend called to make an appointment. Just to be sure, he asked whether that physician would accept payment through Medicare. He was surprised to hear, “No, we do not accept Medicare or any other insurance.”
That’s right! Our friend had found his way to a surgeon who catered to professional athletes – the kind of ultra-wealthy clients who don’t even ask how much an operation will cost.
So what did our friend do? He said thanks, hung up the phone, and started to look for another surgeon who would accept payment from his Medicare policy.
Why Are We Telling You this Story?
It’s to illustrate that sometimes, the physician you want to visit will not accept payment at all through Medicare policies. At other times – and this is common – a physician will be “out of network,” which means that he or she will not accept full payment through the plan you have.
It’s complicated, right? But here are some steps to take to be sure you find your way to a care giver who will accept full payment from your Medicare Advantage or any other plan that you have purchased from a commercial insurance company.
Basic Move: Contact Your Plan and Ask for a List of Care Providers Who Participate
You can do this in two ways. First, you can call your plan provider and ask whether a physician (or other care provider) you want to visit participates in the plan. (Is “in network.”) You will find the number to call on the back of the card that the plan provider gave you.
Or you can visit your plan’s website and use the provider search tool you will find there to look for providers who take part in your plan. Every plan has a searchable directory – you can search by area and by specialty.
Another way to make sure you visit only care providers who are in network is to enroll in a Medicare plan that covers the doctors you see from teh start..you can contact CoverRight and speak with one of the licensed insurance agents who are on staff there. This is a vital step to take when you are shopping for a new plan too – and there is no charge to you for using the CoverRight service.
Double-Safety Check: Call the Doctor’s Office to Confirm that They Are in Your Plan’s Network of Participating Care Providers
It is always a good idea to do this before you make an appointment or receive care from any physician – even if he or she is listed as someone who participates in your plan. You never know, things might have changed. By verifying their participation ahead of time, you can avoid unpleasant surprises. Like being told, “We do not participate in your plan.”
In Summary . . .
Chances are good you will be able to find a doctor or other care provider who accepts payment from your Medicare plan – probably even a highly capable care provider you really like.
Yes, you can find one. But to be sure their fees will be covered by your plan, be sure to ask questions first.