Is Your Doctor A "Participating", "Non-Participating", or "Opt-Out" Provider?

Did you know that your Medicare Part B costs will vary after you meet the deductible depending on the provider type you see? It is very important to check what type of provider you are visiting. If you do not, you could experience unexpected high medical bills.

If you do not know what a provider type is, it determines your cost for Part B services. There are three different types of providers. All of these types have different agreements with Medicare on how they will impact a patient's service costs. 

3 Provider Types:

  1. Participating is the of type that accepts Medicare’s approved amount. For Medicare to pay your provider in full, you must submit a claim (a bill). Keep in mind, you are required to cover the cost of 20% coinsurance.
  2. Non-participating will accept Medicare but may not pay in full payment for certain cases. These types of providers charge 20% coinsurance and a limiting charge of 15% for Medicare’s approved amount for your service fee. After paying cost in full and submitting a claim, you should be sent an MSN (Medicare Summary Notice). This will be your reimbursement for the approved amount by Medicare for 80%.
  3. Opt-out is the provider who will not accept Medicare, which allows them to charge any cost for their services. These providers do not provide bills to Medicare for their services, so it is important to note that you are fully responsible for payment.

How do I find what type of providers are in my area?

If you want to find out what type of providers are near you, you can search by clicking this link: https://www.medicare.gov/physiciancompare/.

How can MWG Senior Services help you?

If you would like to talk with someone about Medicare and retirement insurance, be sure to call MWG Senior Services at (877) 759-5760 or email seniorservices@morganwhite.com. Our team of advisors are ready to answer any questions you might have about the health costs you can prepare for in retirement.