Blog: The Senior's Advocate

How Does Medicare Participation Work?

Breaking Down Medicare Contractual Obligations of Physicians

The world of Medicare can be very confusing for the average senior- it’s tricky language, underlying politics and ambiguity makes it difficulty to fully grasp. Finding a participating doctor can also be a daunting task- especially when the participation isn’t very clear. There are three contactual options for physicians: Participating, Non-Participating and Opt-Out. 

Participating: If a physician is a participating physician, this means that they agree to take assignment on all Medicare claims- meaning they agree to the terms of Medicare and fully accept it. There are incentives in place for physicians to be participating, including being listed in directories as participating, better rates and more. Participating doctors are not hard to find, problem is that Medicare only covers 80% of costs, which is why most people would benefit from owning a supplemental Medicare insurance plan. 

Non-Participating: If a physician is non-participating, it means that they still accept Medicare, but on a case by case basis. This also means that they can charge over and above what Medicare covers if they choose to. They also pay higher rates- so it is in their best interest to weigh out their total annual revenues before deciding whether to be PAR or NON PAR. 

Opt-Out: This means that the physician has chosen to use health care services outside of the Medicare system. They do not acknowledge Medicare as a form of payment and in fact, once a physician has opted out, they cannot submit any Medicare claims. 

Whichever physician you choose, make sure it is the right fit for your needs! And remember- when you’re on a basic Medicare plan paired with a supplemental insurance, you have great coverage. 

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