Understanding health insurance can be tricky, but it becomes easier once you learn more.
Medicare is a type of health insurance that is specifically for adults over 65 and some people with severe chronic illnesses.
Medical expenses can be significant, but having health insurance can help save money in the long run.
Not all doctors accept Medicare, and not all of them belong to a provider network.
It may not be necessary for you to change Medicare doctors if your current one isn’t part of your provider network, though you may still want to do so.
There are easy ways for you to find a doctor near you who accepts Medicare.
Good health does not come cheap. In fact, national health spending in the United States was around $3.8 trillion in 2019, and it’s estimated to grow up to $6.2 trillion by 2028. Even with health insurance, American adults over 65 years old spend the most on healthcare among all age groups, averaging over $11,000 per year. So imagine how much the costs can be if you pay out-of-pocket. Health insurance exists to help you get quality care for a reasonable price, with many different plans available for your needs. And if you’re over 65, that’s where Medicare comes in.
What is Medicare?
Medicare is the federal health insurance program offered by the US government that’s specifically made for those who are 65 years old and over, younger people with certain disabilities, and those who have been diagnosed with end-stage renal disease (ESRD; permanent kidney damage that requires dialysis or a transplant). It’s made up of three parts, each covering specific services, namely:
Part A: inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care
Part B: outpatient care, certain doctors’ services, preventive services, and medical supplies
Part D: prescription drugs, as well as recommended shots or vaccines
Part A: hospital insurance
Part A is usually premium-free for most people, which means that you don’t need to pay a monthly premium to get coverage. If you’re not eligible for premium-free part A, you can still buy it, but you’ll have to pay a premium of up to $471 every month (in 2021), depending on how long you or your spouse worked and paid taxes for Medicare. If you paid for less than 30 quarters, the standard premium for part A is $458, but if you paid for 30–39 quarters, the standard premium is cheaper at $259. Basically, the longer you work and pay for Medicare taxes, the lower the premium will be.
Part B: medical insurance
Unlike part A, anyone who’s enrolled in part B will have to pay a monthly premium. If you do not sign up for part B when you’re first eligible, you may have to pay a late enrollment fee, which can go up to 10% for each year that you could have had part B. You’ll also have to pay this penalty every time you pay your premium for as long as you’re enrolled in part B. The premium will be automatically deducted from your benefits payment if you have benefits from Social Security, Railroad Retirement Board, or Office of Personnel Management. But if you don’t get benefits from any of these, you’ll receive a bill. Most people pay a standard premium amount for part B, which is $148.50 for 2021. But the higher your yearly income is, the more expensive your premium becomes.
Part D: prescription drug coverage
If you want to get coverage for prescription drugs, you’ll have to join a Medicare-approved plan such as Medicare drug plans or Medicare Advantage Plans. These choices can vary in cost and what drugs are covered, so you’ll have to go through them and choose the plan that would benefit you the most, depending on what drugs you need.
Learn more about Medicare and your options.
Why should I choose a doctor who accepts Medicare?
It’s only natural for people to get sick at some point in their lives, especially as they age. The US government created the Medicare health insurance program specifically with the older population in mind. As people advance in years, their health costs often become greater, while their income usually becomes lower. Before Medicare was introduced, only a little over half of American adults over the age of 65 had some form of hospital insurance, and even fewer had insurance that helped cover surgical and physician costs. This means that the majority of older people had to pay for their medical expenses in full. If you’re enrolled in Medicare and choose a doctor who accepts it, you’ll know exactly how much you’ll be paying and won’t have to worry you might get a bill that’s going to drain your life savings.
Learn more about how to shop for Medicare insurance.
When do I have to use Medicare doctors within a provider network?
A provider network is a group made up of doctors, other health care providers, hospitals, and facilities that’s under a contract to provide medical care to people who are part of a certain plan. Depending on what type of plan you have, it may only help cover your care if you see someone who’s part of the provider network. That being said, you don’t necessarily have to use Medicare doctors within the provider network. But if you choose someone who’s outside of the network, you may have to pay more and/or get a referral. Different types of plans that use provider networks include:
Preferred Provider Organizations (PPOs): you pay less if you use providers within the network, and you can still use providers outside of the network without a referral for an additional cost.
Point-of-Service (POS) plans: you pay less if you use providers within the network, but you’ll need to get a referral from your primary care provider to see specialists.
Health Maintenance Organizations (HMOs): you can only use providers within the network and you won’t be covered for care outside of the network (except for emergencies). You may also need to live or work in the area that’s specifically assigned to be covered by the network.
Exclusive Provider Organizations (EPOs): you’re only covered if you use providers within the network (except for emergencies).
HMOs and PPOs are the two most common insurance plans in the US. Learn more about the differences between an HMO and PPO.
Do I have to change Medicare doctors if my current one isn't part of the provider network?
If your current doctor isn’t part of the provider network of the plan you’re on, you can either change your doctor or change to a plan that your doctor belongs to. You can also stay with your existing plan and not change doctors, but that will mean paying a lot more money. If you want to change your doctor, check the provider directory of the plan you’re on for a list of doctors who accept your current plan, and make sure that they’re accepting new patients. You can then make the change on your online account, or call your plan so that they can make the change for you. If you want to change your plan, you can do so during the open enrollment period (November 1, 2021 to January 15, 2022). If you want to change your plan outside of Open Enrollment, you can only do so if you have a life event that qualifies you for a special enrollment period, and you may have limited options.
Learn more about mistakes to avoid during Medicare enrollment.
How do I find a doctor who accepts Medicare near me?
There are many ways for you to find doctors in your area who accept Medicare, such as:
Going to the Physician Compare tool found on the Medicare website. There, you’ll be asked to enter your Zip code and choose a provider type (e.g., doctors, hospitals, nursing homes), and you also have an option to search for a specific provider by typing in their name. With this tool, you’ll be able to find information based on your needs and make informed decisions about where to get your care. You can even look up doctors in your area and compare them side by side. In addition, you can use the Medicare website to look for information on what services your Medicare plan covers.
Call 1–800-MEDICARE (1–800-633‑4227). If you’re having trouble with the Medicare website, you can call Medicare directly and a representative will be able to help you with the search. They can also send you a printed copy of the search results.
Check your insurance company’s provider network. If you have Medigap or a Medicare Advantage Plan, your insurance is partly covered by a private insurance company. You’ll need to check with them to know which doctors near you accept the plan you’re on.
When looking for a doctor, some things to consider include their proximity to you and whether or not they accept your health insurance. There are many resources available for you to find information, which you can do with a simple search online or by making a phone call.