What does Medicare not cover?



In order for Medicare to cover your doctor visit or hospital stay, the first step is to be sure that the doctor or hospital you are using is a Medicare provider. According to a recent study, more than 99% of doctors are Medicare providers. That certainly gives you pretty good odds that your doctor or hospital will be a Medicare provider. It is still possible though, to find one who is part of the 1% who is not a Medicare provider. There are two easy ways to make this determination; First, you can ask your doctors office if they will submit the claim to Medicare for you. If they say yes, you know they are a Medicare provider and Medicare will pay 80% of the approved amount. If the doctor’s office says no, you will want to follow up by asking them to confirm that they have “opted out” of Medicare.

I suggest asking it in this way to avoid confusion on the accept assignment as opposed to being a provider issue. We have often discussed that concept in this column. In short, being a Medicare provider means that Medicare will pay on the claim. Accepting assignment means the doctor agrees to accept what Medicare approves as payment in full, and will not balance bill you above the allowed amount up to the original charge. If the doctor does not accept assignment, he/she can bill you the difference between what Medicare Approved, and what the original charge was. Be informed though, that the government does dictate to Medicare Providers what they can charge in the first place. Medicare doesn’t cover everything. If you need certain services that Medicare doesn’t cover, you’ll have to pay for them yourself unless you have other insurance or you’re in a Medicare health plan that covers these services.

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