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1. Doctors who don’t accept Medicare won’t file claims for the services they provide. Direct payment to your doctor for the full cost of your healthcare would be required.
2. Medigap Coverage: Medigap plans only cover services Medicare approves and pays for; therefore, they don’t cover services outside Medicare’s payment system. Therefore, if a doctor does not accept Medicare, your Medigap plan wouldn’t cover those costs because there’s no Medicare-approved amount for the service.
3. Exceptions: Some Medigap plans like Plan F, High-Deductible Plan F, and Plan G cover “excess charges” which occur when a doctor does not accept Medicare assignment but still treats Medicare patients. These excess charges can be up to 15% more than Medicare’s approved amount for participating providers. However, this only applies if the doctor accepts Medicare patients but does not accept assignment, not if they outright do not accept Medicare at all.
4. Out-of-Pocket Costs: If you see a doctor who does not accept Medicare, you would pay 100% of the bill out of pocket. There would be no reimbursement from either Medicare or your Medicare Supplement plan.
5. Finding Alternatives: It’s advisable to find doctors who accept Medicare assignment to ensure your Medigap plan can function as intended. Tools like Medicare’s Physician Compare can help you locate such providers.

There are other concerns you need to be aware of if your doctor does not accept Medicare, including:

1. Higher Out-of-Pocket Costs: Without Medicare coverage, you’ll have to pay the full cost of services, which can be significantly higher than what you would pay if the provider accepted Medicare. This could lead to substantial financial strain.
2. No Medigap Coverage: As previously mentioned, Medigap policies only cover expenses associated with services that Medicare has approved. If a doctor doesn’t accept Medicare, your Medigap plan won’t cover those costs, leaving you with no insurance support for those visits.
3. Quality of Care Concerns: Medicare has standards and processes for provider participation, including credentialing. Doctors outside of this system might not adhere to the same quality control or oversight. Although not all non-Medicare providers offer lower quality care, there’s less assurance of meeting Medicare’s standards.
4. Managing Multiple Health Issues: Care coordination is vital when dealing with multiple health problems. Doctors outside the Medicare system might not have access to your Medicare-related health records or communicate effectively with other providers who are within the Medicare network, potentially leading to gaps in care.
5. Medication Management: If you’re on medications covered by Medicare Part D, a doctor not accepting Medicare might not be as familiar with formulary restrictions or how to manage your prescriptions within the Part D framework, which could affect your medication regimen or costs.
6. No-Cost Preventative Care: Medicare covers a wide range of preventive services at no cost for its beneficiaries who see participating doctors. Non-Medicare doctors might charge for what would otherwise be free under Medicare, reducing your access to preventive care which can be crucial for health maintenance.
7. Future Healthcare Needs: If your health condition worsens or you require more complex care, having a network of providers who accept Medicare can be beneficial for referrals, specialist consultations, and hospital affiliations that are covered.
8. Potential for Billing Disputes: Since there’s no standard pricing or billing oversight from Medicare, you might encounter higher charges or billing practices that you wouldn’t if the provider was within the Medicare system.

Since its introduction in 2010, the Medigap Plan N has steadily grown in popularity. The lower premium and option to still go to the doctor of your choice without network limitations makes it a great alternative to restrictive Medicare Advantage plans. And now with the huge changes to Plan F and Plan G because of the Medicare Access and CHIP Reauthorization Act (MACRA) law going into effect on January 1, 2020, Plan N is now the best Medicare supplement plan for your long-term financial goals. We look at the reasons why in this article.

Mutual of Omaha is our preferred provider for Plan N.
Click here to find premiums for your area and enroll online.

Medicare Guaranteed Issue Plans Changed in 2020

We mentioned above that MACRA changed Plan F. Since the beginning of the Medicare lettered, standardized plans in 1991, Plan F has far outsold all the other plans combined. It covered every deductible and co-payment under original Medicare.

But as of January 1, 2020, Plan F was no longer available to people who were new to Medicare. If you have a Plan F, I would highly recommend that you consider a different plan. You will need to be medically qualified to change from Plan F. If you are not sure, call us and we can help you determine if you can make a change. Since there are will be no new, healthy enrollees coming into Plan F, we expect that Plan F rates will rise exponentially, just as other discontinued plans have in the past.

Read our article – Why We No Longer Recommend Plan F

Another way that MACRA affected Medicare coverage is in how it handles Guaranteed Issue enrollees. New Medicare enrollees starting in 2020 have a choice of Medigap Plan D, Plan G, or the new High-Deductible Plan G.

Differences Between Open Enrollment and Guaranteed Issue

Open Enrollment refers to the period when I person is first eligible for Medicare coverage under Part B. For most people, this is when they turn 65 years old. People who continue to work past the age of 65 can postpone their enrollment in Part B in many cases. For these workers, Open Enrollment will begin when they leave group coverage and enroll in Part B.

Guaranteed Issue enrollees are generally people who are losing creditable coverage through an employer. It also includes certain people who are moving out of a Medicare Advantage plan’s coverage area or whose Medicare Advantage plan is being discontinued. These enrollees are eligible to enroll in certain Medigap plans with no underwriting.

Plan Choices Are Limited For Guaranteed Issue

Until 2020 brought new changes, they could enroll in Medigap Plan A, B, C, F, K, or L. Today, when a person qualifies for a Guaranteed Issue plan, Medicare will limit them to Plan D, G, or HDG unless they can qualify for another plan like Plan N through underwriting.

If they are not medically qualified to go with the plan of their choice, this limitation will apply. That means that – just as it was with Plan F under the old Guaranteed Issue rules – Plan G will be taking on enrollees who are sicker or have pre-existing conditions. This will lead to higher claims for Plan G across the board, which leads to higher premiums.

Click on the video to see why I recommend Plan N over other Medigap plans:

Coverage Under Medigap Plan N

So the big question becomes – how is Medigap Plan N different from Plan G? Here is a chart from the official Medicare and You booklet. It shows the coverage of each lettered plan:

There are three primary coverages that Plan N does not offer compared to Plan F or Plan G:

• Like Plan G, the Medigap Plan N does not cover the Part B deductible
• You may have an office visit co-payment of up to $20 per visit and a $50 co-payment for emergency room visits that do not result in a hospital admission
• Plan N does not cover excess charges

Medicare supplement Plan N does not cover the Part B deductible. After you meet your Part B deductible, Medicare covers 80% of Part B covered charges. Plan N covers the other 20% for you.

Plan N Co-pays

You will be responsible for a co-payment of up to $20 per office visit to a physician. This co-payment does not apply to physical therapy or occupational therapy visits, as well as some other visits. 

There is also a $50 co-payment for emergency room visits. Being admitted to the hospital within 24 hours of this ER visit means that Part A will cover all charges. In that case, you will not be required to pay the $50 co-payment. If the hospital treats and releases you from the ER, you will owe the $50 co-pay.

Medigap Plan N Does Not Cover Excess Charges

Not covering Excess Charges really is not as bad as it sounds. Medicare has assigned prices for any procedure that a physician performs on your behalf. Every procedure has a Medicare code and a price that Medicare approves for that procedure or visit. If your doctor accepts “Medicare Assignment,” or in other words the assigned price, they will accept the predetermined amount from Medicare as payment in full.

Less than 4% of doctors choose to not accept Medicare Assignment. When they do not accept this payment, they can charge the patient 15% more than the Medicare-assigned price for that procedure. That extra amount is the excess charge. One way to avoid any excess charges is to ask your doctor if they accept Medicare assignment.

**There are some states that do not allow any excess charges to be billed to the Medicare beneficiary. As of 2024, these states include Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont. If you live in one of these states, you can enroll in a Plan N with no concern about having to pay excess charges.

Here is a report about excess charges from one of the largest Medicare insurers:

In August 2016, Aetna reported that 99.34% of the claims they process have no excess charges. Of the 0.66% of claims that do have Medicare excess charges, the average amount of the charge is less than $20.

See our article for full details – Medicare Excess Charges, Should I Be Concerned

To see what would be the best option for your personal situation, call us at 1-888-228-6119 or use the form to send a request.

Stanley Keith Murray is an independent agent and the founder of Integrity Senior Solutions Inc. He has been working with Seniors to meet their insurance and financial needs since 1996.