Medicare Providers

Primary care physicians are just one type of Medicare provider. Original Medicare (Part A and Part B), Medicare Advantage (Part C) or Medicare Supplement plans may also cover other services and facilities.

Original Medicare beneficiaries have access to doctors and health care facilities throughout the United States. Recipients may be limited to a provider network depending on additional coverage purchased.

According to a 2022 survey by the Kaiser Family Foundation, virtually all primary care providers accepted Medicare while only a small fraction — 3% according to a 2020 KFF analysis — opt-out. The 2022 survey also found that 89% of non-pediatric primary care providers accept new Medicare patients.

Original Medicare participating providers accept Medicare and most take assignment.

Many Medicare Advantage plans maintain provider networks.

Most Part C plans, including Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plans, require you to utilize a network of Medicare providers in order to reduce cost. This means that some doctors and health care facilities may be excluded from your network, even if they are Medicare-certified providers.

You can still visit these out-of-network providers — but your care will cost more.

However, these rules don’t apply to emergency care. Medicare Advantage plans must still cover emergency room expenses at in-network rates, even if you use an out-of-network facility.

Each Medicare Advantage plan is required to include an adequate number of in-network providers and hospitals.

To become Medicare certified, providers must complete an application form and pass inspection by a state government agency.

Once Medicare approves a provider, they are assigned a National Provider Identifier and a Medicare billing number.

Not all providers accept Medicare.

Nonparticipating providers accept Medicare but do not agree to take assignment in all cases. These providers can charge up to 15 percent more than the official Medicare reimbursement amount.

In other words, you can still visit a nonparticipating provider — but it’s likely to cost you more money.

It’s important to note that you may be able to cover some or all of these extra expenses — known as excess charges — with a Medigap Supplement insurance policy or Medicare Advantage plan.

Some states don’t allow excess charges at all.

Opt-out providers do not accept Medicare at all. These doctors and health care facilities can charge whatever they want for services and you will be responsible for the entire cost of your care. Opting out of Medicare means those providers can’t see Medicare beneficiaries without disclosing the full cost of care up front and entering into a private contract where the patient agrees to bear responsibility for the full price of services rendered.

As of April 2022, about 28,000 providers have opted out of Medicare — and 43% of those worked in behavioral health disciplines, according to an analysis of Medicare data by Behavioral Health Business.