Why does my doctor no longer accept Medicare? What happens if my doctor leaves my Medicare Advantage network?

Why does my doctor no longer accept Medicare? What happens if my doctor leaves my Medicare Advantage network?

A doctor or provider may decide to “opt out” of Medicare for various reasons. For example, a practice may feel the need to reduce overhead costs or wish to keep the number of patients down in order to maintain a suitable level of care.

If your doctor opts out of Medicare, this means that he or she is no longer enrolled in the Medicare program and does not submit any claims to the federal program or Medicare health plans. The doctor becomes exempt from Medicare-approved spending limits.

Impact of a Doctor Opting Out of Medicare

If your doctor opts out of Medicare, you become responsible for paying the complete cost of your health care if you stay with that doctor. Because your costs are lowest if you see a Medicare-participating doctor or provider, you may want to consider making a change.

Participating providers agree to “accept assignment” for all Medicare-covered services. This means that they will not charge you above the Medicare-approved amounts for a service. You will still be responsible for any cost sharing that may apply including copayments. coinsurance, or deductibles.

Using Your Doctor as a Non-Participating Provider

Other situations may occur where your doctor remains in the Medicare program, but can choose on a case-by-case basis whether or not to accept Medicare assignment. This is known as a “non-participating provider.”
If a doctor does not accept Medicare assignment for a given service, it means he or she does not accept the Medicare-approved cost amount and can charge you up to 15% more for their services. This is known as a “limiting charge.”

Switching to a Medicare-Participating Doctor or Provider

Original Medicare (Part A and Part B)

If you’re enrolled in Original Medicare and your doctor opts out of the Medicare program, you can find doctors who accept Medicare through <link>Medicare.gov’s Physician Compare website<link>. This site is a national database of physicians, specialists, and other health-care professionals who are enrolled in the Medicare program. 

The site includes both participating and non-participating providers. It is hassle-free and easy to use. The filter will help you search for doctors that accept assignment.

Use the Physician Compare tool to search for doctors and providers by:

  • Location and zip code
  • Area of practice (for example, cardiology)
  • Gender
  • Hospital affiliation
  • Your doctor’s last name

After entering in your search criteria, the Physician Compare page will display a list of doctors in your area that meet your requirements. It is always a good idea to call to confirm that the provider accepts Medicare assignment and is taking new patients.

Medicare Advantage

Switching to a new Medicare Advantage plan generally needs to be done during the Annual Election Period which runs from October 15 to December 7. A patient may do this if his or her doctor is part of another Medicare Advantage plan’s provider network.

In some situations, the Centers for Medicare & Medicaid Services (CMS) may decide that the change in provider network was significant enough to warrant a Special Election Period. If this applies to you, your Medicare Advantage plan will notify you. You may then use the Special Election Period to either enroll in another Medicare Advantage plan or return to Original Medicare.

Times when you may be eligible for a Special Election Period may include, but are not limited to:

  • Your Medicare Advantage plan does not renew its plan contract or reduces its service area for the upcoming plan year.
  • Your Medicare Advantage plan substantially changes its contract with CMS.
  • Your Medicare Advantage plan violates its contract with CMS.
  • CMS terminates your Medicare Advantage plan’s contract as a result of misconduct or other problems.

The rules about what you can do may vary depending on the situation that prompted the Special Election Period in the first place.

Disenrolling from your Medicare Advantage plan and returning to Original Medicare is also an option. If your doctor is no longer in the provider network for any Medicare Advantage plan (but is still accepting Medicare), you may decide to go back to Original Medicare in order to continue seeing him or her. You can use the Annual Election Period (or the Special Election Period in some circumstances) to disenroll and return to Original Medicare.

You can also disenroll from your plan during the Medicare Advantage Disenrollment Period (January 1 to February 14). In addition, you can use this disenrollment period to enroll in a stand-alone Medicare Prescription Drug plan.

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Why does my doctor no longer accept Medicare? What happens if my doctor leaves my Medicare Advantage network?