Medicare Part A (hospitalization) and Medicare Part B (medical coverage) has been available since 1965. Health Care has changed a lot since those beginning years. Medicare Part D (Prescription Drug coverage) began in 2006. Many assume that all physicians and hospitals participate in Medicare, but that is not true. Medicare is probably the most widely accepted insurance product on the market today, but there are physicians who do not accept Medicare reimbursement.
More than 95% of physicians within the United States participate in Medicare. When physicians “Participate” with Medicare, they must always accept Medicare “assignment”. This means that they must accept as payment what Medicare allows (or pays) for that procedure, office visit, etc. This assignment (payment) is often significantly less than the amount they bill for that service. Medicare pays the physician directly at 80% of the assigned value of the visit. The 20% left over is billed to you or your secondary insurance. To put this in dollars: you see your physician for an office visit, and he bills $175 for the visit. Medicare approves the assignment at $100, so Medicare pays $80. You or your secondary coverage pays the remaining 20% or $20.
When physicians are “Non-Participating” providers, they don’t routinely take assignment. These physicians can bill Medicare, but don’t accept what Medicare “Assigns” as full payment. This group of physicians will require that you pay more than the Medicare-approved amount. These Non-Participating Physicians can only bill their patients up to 15% above the Medicare Assignment amount nationally for their services. In New York State this additional amount can only be 5% above Medicare Assignment. To put this in dollars: you see your Non-Participating physician and he bills $175 for the visit. Medicare assignment is $100, so Medicare pays $80. The physician would then expect you or your secondary coverage to pay $25 in New York State, and $35 in most other states. These Non-Participating physicians can also request full payment up-front for services, and Medicare would then send you the check for $80.
The third group of physicians are those providers who have “opted out” of Medicare altogether. They cannot bill Medicare for any services (except in some cases of emergencies). This group of physicians are required to inform you of this Opt-Out in advance, and you are required to sign a written agreement up front, before being seen. This group of physicians can charge whatever they want for services rendered. A common situation for this type of practitioner is Chiropractors. Many Chiropractors give you a per visit charge and do not bill any insurance.
Most physicians in the USA participate in Medicare. Original Medicare does not require permissions or referrals for health care. So as you travel around the United States you can use your Original Medicare card with few exceptions anywhere you wish. In our area it would be difficult to find a non-participating physician, although periodically I come across one.
It is important to remember that participating in Medicare does NOT indicate participating in the many hundreds of alternative insurance products available such as Medicare Advantage Plans. These plans have their own network of providers and hospitals based on their type of coverage, Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO). This is important to consider when you switch insurance product choices each year, particularly for Medicare Advantage Plans.
In your situation as you travel, your Original Medicare and your Medicare Supplement Plan (Medigap) are useful nationally. These products rarely require prior approval or referrals for services. When and if you need care while traveling your coverage should be completely portable and comprehensive.
Show the providers your insurance cards, using the terms Original Medicare and Medicare Supplement (Medigap) coverage. Most Insurance companies sell almost all the different types of products, Medicare Supplement Plans, Prescription Drug Plans and Medicare Advantage Plans (PPO & HMO). If you ask the provider “Do you take ____________?” (Humana, Univera, BC/BS, or United Healthcare, just to name a few). You may not get a correct answer. This would be like asking someone, “Do you drive a Ford?” There are lots of different types of Ford vehicles. Be very specific about the insurance product you have when speaking with your providers.
Safe Travels! Enjoy all these United States have to offer!