What to do if your doctor doesn't accept Medicare?

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If your doctor does not accept Medicare, you must determine their specific status—whether they are non-participating or opt-out—and choose to pay out-of-pocket, negotiate fees, or switch to a provider who accepts Medicare.

1. Identify the Provider's Status

Ask the doctor's billing office directly to clarify how they handle Medicare:

  • Non-Participating Providers: They do not have a standard agreement with Medicare, but they may accept Medicare on a case-by-case basis. They can legally charge up to 15% more than the Medicare-approved amount (known as a "limiting charge"). You will likely have to pay the difference out-of-pocket.
  • Opt-Out Providers: They have formally opted out of the Medicare program for at least two years and sign a private contract with you. Medicare will pay zero for any services you get from them (except in a true medical emergency), and you are responsible for 100% of the bill.

2. Your Options If You Stay With the Doctor

  • Pay out-of-pocket: Cover the extra balance or the full bill yourself. If they are non-participating, you may need to pay upfront and submit Form CMS-1490S to get what Medicare owes you.
  • Negotiate a cash discount: Ask if the office offers a lower rate for cash payments or an extended payment plan for regular visits.
  • Check your plan type: Clarify whether the doctor rejects Original Medicare or a specific Medicare Advantage plan. If they take a different Medicare Advantage plan, you might be able to switch plans during the Annual Open Enrollment Period (October 15 to December 7).

3. Alternative Ways to Get Care

  • Ask for a referral: Ask your current doctor to recommend a colleague or clinic nearby that does accept Medicare.
  • Use urgent care centers: Most walk-in urgent care clinics accept Medicare for minor illnesses and short-term needs.
  • Find a new doctor:
    • Use the Medicare.gov Provider Directory to search for participating local physicians.
    • Call 1-800-MEDICARE (1-800-633-4227) for assistance finding a provider.
    • Reach out to your state's State Health Insurance Assistance Program (SHIP) for free, unbiased guidance.

What happens if a doctor does not accept Medicare after?

If a doctor does not accept Medicare, you will face higher out-of-pocket costs or have to pay the full price for your visits, depending on whether the provider is nonparticipating or has opted out of the program.

Nonparticipating Providers

A nonparticipating doctor does not sign an agreement to accept Medicare’s approved rates for all services, but they may still see Medicare patients.

  • Balance billing: They can charge up to 15% more than the official Medicare-approved amount for a service, and you must pay that extra cost.
  • Payment rules: You may have to pay the entire bill upfront, and either the doctor or you must submit a claim to Medicare for partial reimbursement.

Opt-Out Providers

An opt-out doctor rejects Medicare entirely and signs a private contract with you.

  • Full cost: You must pay 100% of the doctor's charges out of pocket.
  • No reimbursement: Medicare pays nothing toward these bills, except in sudden medical emergencies.

Your Options

  • Switch doctors: Ask your current physician for a referral to a local doctor who accepts Medicare Assignment.
  • Use clinics: Visit a local urgent care center or walk-in clinic, as most of them accept Medicare for basic and non-emergency needs.
  • Check insurance: If you use a Medicare Advantage plan, verify if the doctor belongs to that specific private network.

What are the 5 things Medicare won't cover?

Original Medicare (Parts A and B) does not cover routine dental care, routine eye exams and eyeglasses, hearing aids and routine exams, long-term (custodial) care, and routine foot care.

Major Gaps in Original Medicare

  • Most Dental Care: Routine cleanings, fillings, tooth extractions, dental plates, and root canals are completely excluded from coverage.
  • Routine Vision Care: Regular eye exams, eyeglasses, and contact lenses are not covered, though treatment for specific diseases like cataracts or glaucoma is included.
  • Hearing Aids: Standard Medicare does not pay for hearing aids or routine fitting exams.
  • Long-Term Care: Assistance with daily personal needs (such as bathing, dressing, or eating) in a nursing home or at home is not covered if it is non-skilled custodial care.
  • Routine Foot Care: General podiatry services like trimming toenails or removing corns and calluses are excluded (with narrow exceptions for conditions like severe diabetic neuropathy).

What percentage of physicians do not accept Medicare?

Around 1.2% of active non-pediatric U.S. physicians have formally opted out of Medicare, meaning roughly 98% to 99% participate in the program to some degree.

Understanding Doctor Participation

  • Participating Providers: Roughly 90%–98% of doctors accept Medicare's standard payment rates and assignment rules.
  • Non-Participating Providers: These doctors accept Medicare but do not always take assignment. They can charge up to 15% more than the Medicare-approved amount for certain services.
  • Opt-Out Providers: Only about 1.2% have completely signed private contracts outside of Medicare, requiring patients to pay out-of-pocket without Medicare reimbursement.
  • New Patients: About 89% of office-based physicians accept new Medicare patients.

Rates by Specialty

  • Highest Opt-Out Rates: Psychiatrists have the highest opt-out rate at 8.1%, followed by plastic and reconstructive surgeons at 4.5%.
  • Lowest Opt-Out Rates: Emergency medicine physicians, oncologists, and radiologists have opt-out rates of 0.1% or less.

Why are doctors not accepting Medicare patients?

Some doctors choose not to accept Medicare because of low reimbursement rates, high operating costs, and heavy paperwork.

Low Reimbursement Rates

  • Medicare often pays doctors less than private health insurance plans for the exact same medical services.
  • Many physicians feel that these official payment rates have not kept up with general inflation or the rising costs of running a medical office.
  • Most users on Reddit agree that low reimbursement makes it hard to pay for staff salaries, rent, and basic medical equipment.

High Administrative Burdens

  • Medicare and private Medicare Advantage plans require "prior authorization" for many common tests, procedures, and specialist referrals.
  • Doctor offices spend many hours every week fighting claim denials and handling complex paperwork instead of seeing patients.
  • These strict rules and regulatory penalties cause severe burnout for many healthcare workers.

Practice Capacity and Patient Mix

  • Operating a sustainable medical practice requires balancing different types of insurance, known as a "payer mix".
  • Because Medicare payments are fixed and low, some independent clinics limit the number of Medicare patients they take on to avoid losing money.

What happens if a doctor does not accept Medicare?

9 related questions found

Can I be reimbursed if my doctor is not participating in Medicare?

You can be reimbursed by Medicare only if your doctor is a non-participating provider, but you will receive no reimbursement if the doctor has completely opted out of Medicare.

Reimbursement Rules by Provider Status

  • Non-Participating Providers: These doctors are enrolled in Medicare but do not accept assignment for all services. You may need to pay the bill upfront and file a claim to get paid back for the Medicare-approved amount. They can legally charge you up to 15% over the Medicare-approved amount (the limiting charge), which you must pay out of pocket.
  • Opt-Out Providers: These doctors have signed a private contract agreeing not to bill Medicare at all. Neither you nor the doctor can submit claims, and Medicare will provide zero reimbursement for non-emergency care.

How to Check and File

  • Verify Status: Call your doctor's office and ask if they are non-participating or fully opted-out, or search the Medicare.gov Provider Directory.
  • Submit a Claim: If your non-participating doctor does not submit the claim for you, you can file manually using Form CMS-1490S.

What is the best insurance to have for Medicare?

The best insurance for Medicare depends on whether you want the flexibility of Original Medicare with a supplement or the bundled perks of a private plan, with Humana and Aetna leading for Medicare Advantage and AARP/UnitedHealthcare leading for Medigap supplements.

Choosing the right coverage requires looking at the two main paths available to you.

Option 1: Original Medicare + Medigap (Best for Freedom of Doctor Choice)

Original Medicare is run by the federal government (Parts A and B). It does not cover everything, so people buy private supplemental insurance called Medigap.

  • How it works: You can see any doctor in the U.S. who accepts Medicare. You do not need referrals to see specialists.
  • Extra needs: You must buy a separate Part D plan for prescription drugs.
  • Top Companies:
    • AARP/UnitedHealthcare: Best overall for wide availability and plan variety.
    • Mutual of Omaha: Best for stable long-term pricing and fast claim approvals.
    • State Farm: Great rates and coverage for specific states.

Option 2: Medicare Advantage / Part C (Best for Lower Monthly Costs and Extras)

Medicare Advantage plans are sold by private insurance companies approved by Medicare.

  • How it works: These plans bundle Part A, Part B, and usually Part D (prescription drugs) into one plan. They often include extra benefits like dental, vision, and hearing.
  • Catch: You must use the plan's network of doctors and may need referrals for specialists.
  • Top Companies (Rated by NerdWallet and government stars):
    • Humana: Top choice for member experience and low-cost plans.
    • Aetna: High government star ratings and many $0-premium options.
    • UnitedHealthcare: Largest network size across the country.

Option 3: Standalone Prescription Drug Plans (Part D)

If you choose Original Medicare, you need a separate drug plan.

  • Top Company: Wellcare stands out for affordable monthly rates and low-cost generic drugs.

What is the big mistake people make with Medicare?

The single biggest and most costly mistake people make with Medicare is missing enrollment deadlines, leading to permanent late-enrollment penalties and gaps in coverage.

Missing Enrollment Deadlines

  • Initial Enrollment Period (IEP): This window lasts for seven months. It starts three months before the month you turn 65, includes your birthday month, and ends three months after.
  • Late Penalties: Failing to sign up for Part B or Part D on time can trigger permanent monthly or yearly financial penalties added to your premiums.
  • Delayed Enrollment Confusion: Many people wrongly assume they can delay Medicare past age 65 just because they have health coverage like COBRA, a marketplace plan, or small-employer insurance.

Other Costly Medicare Mistakes

  • Ignoring Annual Changes: Sticking with automatic renewal without reading the Annual Notice of Change (ANOC) can result in unexpected costs, as drug lists and doctor networks shift every year.
  • Choosing Solely by Low Premiums: Picking a plan based only on a low monthly cost while ignoring total out-of-pocket expenses like deductibles, copays, and coinsurance.
  • Missing the Medigap Window: Forgetting to apply for a Medigap (Medicare Supplement) policy during your open enrollment window. After this six-month period, insurers can use medical underwriting to charge more or deny coverage.
  • Skipping Financial Assistance: Overlooking programs like Medicare Savings Programs or Part D Extra Help that assist with out-of-pocket medical and prescription expenses.

What is no longer covered by Medicare?

Original Medicare Original Medicare Not Covered and Medicare Advantage plans have strict rules regarding items and services that are excluded from coverage.

Expiring & Restrictive Coverage Changes

  • Broad Telehealth Flexibilities: Pandemic-era telehealth waivers expired on January 31, 2026 Medicare telehealth flexibilities expire. Beneficiaries generally must be located in a medical facility and in a rural area to receive covered telehealth services, except for behavioral health care Medicare Will No Longer Cover This Popular Service Starting Jan. 31.
  • Medicare Advantage Non-Qualifying Supplemental Items: CMS rules restrict Medicare Advantage plans from covering non-health items previously allowed for chronically ill enrollees, including alcohol, cannabis, tobacco, unhealthy foods, cosmetic procedures (facelifts), funeral costs, and life or hospital indemnity insurance Medicare Advantage Can No Longer Cover These Items in 2026.

Standard Exclusions in Original Medicare

  • Routine Dental Care: Cleanings, fillings, tooth extractions, and dentures What Medicare will not cover in 2026 | The American Legion.
  • Routine Vision Care: Eye exams for prescription glasses, contact lenses, or eyeglasses (except following cataract surgery) What Medicare will not cover in 2026 | The American Legion.
  • Hearing Care: Routine hearing exams and hearing aids What Medicare will not cover in 2026 | The American Legion.
  • Long-Term Custodial Care: Extended nursing home care or assisted living that only involves personal help with daily living activities What Does Medicare Not Cover? Eight Things You Should Know.
  • Routine Foot Care: Cutting corns or calluses and basic toenail clipping What Medicare will not cover in 2026 | The American Legion.
  • Overseas Care: Medical treatment received outside the United States What Medicare will not cover in 2026 | The American Legion, with rare exceptions.

Does Medicare cover 100% of your medical bills?

No, Original Medicare does not cover 100% of your medical bills.

Out-of-Pocket Costs in Original Medicare

  • Deductibles: You must pay yearly deductibles before Medicare starts paying. For example, Part B has an annual deductible, and Part A has a deductible for each hospital stay.
  • Coinsurance: For most doctor visits and outpatient care under Part B, you pay 20% of the approved cost after meeting your deductible, while Medicare pays 80%.
  • No Out-of-Pocket Cap: Original Medicare (Parts A and B) does not have a yearly limit on your total out-of-pocket spending.
  • Excluded Services: Original Medicare does not pay for routine dental care, eye exams for glasses, hearing aids, or long-term custodial care. It also does not cover prescription drugs unless you add a Part D plan.

How to Get More Coverage

  • Medigap (Supplement): You can buy a private Medigap policy to pay for leftover costs like deductibles and the 20% coinsurance.
  • Medicare Advantage (Part C): You can join a private Medicare Advantage plan that replaces Original Medicare and includes a yearly limit on out-of-pocket costs.