What happens if my doctor no longer accepts Medicare payment?

While most doctors accept Medicare, some do not. If you turn 65 and your physician does not accept Medicare, you will have some decisions to make. Choosing to stay with a doctor that does not accept Medicare can result in high out-of-pocket costs for you. There is a difference between a doctor who does not accept Medicare assignment and one who completely opts out of Medicare. If they do not accept Medicare assignment, you may be responsible for an excess charge of up to 15% of a service’s cost. If your doctor opts out of Medicare, you will likely have to pay for 100% of their services out-of-pocket and at commercial rates, which can be significantly higher than Medicare. Unfortunately, if you don’t want to pay those additional out-of-pocket costs, you will have to switch to a doctor that does accept Medicare. If this is the case, talk to your doctor, ask them to recommend a local doctor who does accept Medicare. If your doctor does not accept Medicare, they have probably already prepared for this situation and likely have a Medicare doctor they refer patients to. Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call to discuss the options available to you.

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What are Medicare “star ratings” and how are they measured?

Medicare rates Medicare Advantage and Part D (prescription drug plans) using something called Medicare stars. A 5-star rating is the best, while a 1-star rating is the worst. When you’re trying to choose a Medicare Advantage or Part D (prescription drug) plan, all the choices can be overwhelming. The star rating program was put in place to help you decide which plan is right for you. Medicare Advantage with prescription drug coverage (MA-PD) plans are rated on up to 44 unique quality and performance measures; MA-only plans (without prescription drug coverage) are rated on up to 32 measures, and stand-alone PDP plans are rated on up to 14 measures. The measures used to determine the ratings, including things like the following:

  • How the plan emphasizes staying healthy, including things like screenings, tests, and vaccines
  • How the plan manages chronic conditions
  • The quality of care people with the plan receive
  • Member complaint reports
  • Plan operations, including things like, how they make decisions about appeals, and the results of audits
  • Member experience

You can use the ratings, along with premiums, out-of-pocket costs, and benefits, to choose the right Medicare Advantage plan for you.
Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call at 619.886.5665 to discuss the options available to you.

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What does a Medicare drug formulary with tiers mean?

Every Part D plan has something called a formulary, which is a list of drugs covered under the plan. Each formulary has a set of tiers, and in most cases, Part D plans have between three and six tiers. A lower-tier drug usually has lower copays or coinsurance than a drug in a higher tier.

For example:

Tier 1 – Lowest copay, usually generic drugs
Tier 2 – Medium copay includes some low-cost brand-name drugs
Tier 3 – Higher copay includes brand-name drugs that have generic versions also available
Tier 4 – Higher-co-pay brand-name drugs, and some specialty drugs
Tier 5 – Highest copay includes high-cost specialty prescription drugs

Suppose you are prescribed a drug in a high tier, and a drug that is similar or therapeutically equivalent is also available in a lower-tier at a lower price. In that case, you can ask your insurance company for an exception to get the lower coinsurance or copay.

Call Kevin Leinum Medicare Agent – your local Medicare Expert about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

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We do not offer every plan available in your area. Currently, we represent 8 organizations which offer 75 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options. This is a proprietary website and is not associated, endorsed, or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program, please visit the Official U.S. Government Site for People with Medicare located at http://www.medicare.gov.

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