what percentage of doctors accept medicare assignment

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Balance Billing in Health Insurance

• How It Works
• When It Happens
• What to Do If You Get a Bill
• If You Know in Advance

Balance billing happens after you’ve paid your deductible , coinsurance or copayment and your insurance company has also paid everything it’s obligated to pay toward your medical bill. If there is still a balance owed on that bill and the healthcare provider or hospital expects you to pay that balance, you’re being balance billed.

This article will explain how balance billing works, and the rules designed to protect consumers from some instances of balance billing.

Is Balance Billing Legal or Not?

Sometimes it’s legal, and sometimes it isn’t; it depends on the circumstances.

Balance billing is generally illegal :

• When you have Medicare and you’re using a healthcare provider that accepts Medicare assignment .
• When you have Medicaid and your healthcare provider has an agreement with Medicaid.
• When your healthcare provider or hospital has a contract with your health plan and is billing you more than that contract allows.
• In emergencies (with the exception of ground ambulance charges), or situations in which you go to an in-network hospital but unknowingly receive services from an out-of-network provider.

In the first three cases, the agreement between the healthcare provider and Medicare, Medicaid, or your insurance company includes a clause that prohibits balance billing.

For example, when a hospital signs up with Medicare to see Medicare patients, it must agree to accept the Medicare negotiated rate, including your deductible and/or coinsurance payment, as payment in full. This is called accepting Medicare assignment .

And for the fourth case, the No Surprises Act , which took effect in 2022, protects you from "surprise" balance billing.

Balance billing is usually legal :

• When you choose to use a healthcare provider that doesn’t have a relationship or contract with your insurer (including ground ambulance charges, even after implementation of the No Surprises Act).
• When you’re getting services that aren’t covered by your health insurance policy, even if you’re getting those services from a provider that has a contract with your health plan.

The first case (a provider not having an insurer relationship) is common if you choose to seek care outside of your health insurance plan's network.

Depending on how your plan is structured, it may cover some out-of-network costs on your behalf. But the out-of-network provider is not obligated to accept your insurer's payment as payment in full. They can send you a bill for the remainder of the charges, even if it's more than your plan's out-of-network copay or deductible.

(Some health plans, particularly HMOs and EPOs , simply don't cover non-emergency out-of-network services at all, which means they would not cover even a portion of the bill if you choose to go outside the plan's network.)

Getting services that are not covered is a situation that may arise, for example, if you obtain cosmetic procedures that aren’t considered medically necessary, or fill a prescription for a drug that isn't on your health plan's formulary . You’ll be responsible for the entire bill, and your insurer will not require the medical provider to write off any portion of the bill—the claim would simply be rejected.

Prior to 2022, it was common for people to be balance billed in emergencies or by out-of-network providers that worked at in-network hospitals. In some states, state laws protected people from these types of surprise balance billing if they had state-regulated health plans.

But not all states had these protections. And the majority of people with employer-sponsored health insurance are covered under self-insured plans, which are not subject to state regulations. This is why the No Surprises Act was so necessary.

How Balance Billing Works

When you get care from a doctor, hospital, or other healthcare provider that isn’t part of your insurer’s provider network  (or, if you have Medicare, from a provider that has opted out of Medicare altogether , which is rare but does apply in some cases ), that healthcare provider can charge you whatever they want to charge you (with the exception of emergencies or situations where you receive services from an out-of-network provider while you're at an in-network hospital).

Since your insurance company hasn’t negotiated any rates with that provider, they aren't bound by a contract with your health plan.

Medicare Limiting Charge

If you have Medicare and your healthcare provider is a nonparticipating provider but hasn't entirely opted out of Medicare, you can be charged up to 15% more than the allowable Medicare amount for the service you receive (some states impose a lower limit).

This 15% cap is known as the limiting charge, and it serves as a restriction on balance billing in some cases. If your healthcare provider has opted out of Medicare entirely, they cannot bill Medicare at all and you'll be responsible for the full cost of your visit.

If your health insurance company agrees to pay a percentage of your out-of-network care, the health plan doesn’t pay a percentage of what’s actually billed . Instead, it pays a percentage of what it says should have been billed, otherwise known as a reasonable and customary amount.

As you might guess, the reasonable and customary amount is usually lower than the amount you’re actually billed. The balance bill comes from the gap between what your insurer says is reasonable and customary, and what the healthcare provider or hospital actually charges.

Let's take a look at an example in which a person's health plan has 20% coinsurance for in-network hospitalization and 40% coinsurance for out-of-network hospitalization. And we're going to assume that the No Surprises Act does not apply (ie, that the person chooses to go to an out-of-network hospital, and it's not an emergency situation).

In this scenario, we'll assume that the person already met their $1,000 in-network deductible and $2,000 out-of-network deductible earlier in the year (so the example is only looking at coinsurance).

And we'll also assume that the health plan has a $6,000 maximum out-of-pocket for in-network care, but no cap on out-of-pocket costs for out-of-network care:

When Does Balance Billing Happen?

In the United States, balance billing usually happens when you get care from a healthcare provider or hospital that isn’t part of your health insurance company’s provider network or doesn’t accept Medicare or Medicaid rates as payment in full.

If you have Medicare and your healthcare provider has opted out of Medicare entirely, you're responsible for paying the entire bill yourself. But if your healthcare provider hasn't opted out but just doesn't accept assignment with Medicare (ie, doesn't accept the amount Medicare pays as payment in full), you could be balance billed up to 15% more than Medicare's allowable charge, in addition to your regular deductible and/or coinsurance payment.

Surprise Balance Billing

Receiving care from an out-of-network provider can happen unexpectedly, even when you try to stay in-network. This can happen in emergency situations—when you may simply have no say in where you're treated or no time to get to an in-network facility—or when you're treated by out-of-network providers who work at in-network facilities.

For example, you go to an in-network hospital, but the radiologist who reads your X-rays isn’t in-network. The bill from the hospital reflects the in-network rate and isn't subject to balance billing, but the radiologist doesn’t have a contract with your insurer, so they can charge you whatever they want. And prior to 2022, they were allowed to send you a balance bill unless state law prohibited it.

Similar situations could arise with:

• Anesthesiologists
• Pathologists (laboratory doctors)
• Neonatologists (doctors for newborns)
• Intensivists (doctors who specialize in ICU patients)
• Hospitalists (doctors who specialize in hospitalized patients)
• Radiologists (doctors who interpret X-rays and scans)
• Ambulance services to get you to the hospital, especially air ambulance services, where balance billing was frighteningly common
• Durable medical equipment suppliers (companies that provide the crutches, braces, wheelchairs, etc. that people need after a medical procedure)

These "surprise" balance billing situations were particularly infuriating for patients, who tended to believe that as long as they had selected an in-network medical facility, all of their care would be covered under the in-network terms of their health plan.

To address this situation, many states enacted consumer protection rules that limited surprise balance billing prior to 2022. But as noted above, these state rules don't protect people with self-insured employer-sponsored health plans, which cover the majority of people who have employer-sponsored coverage.

There had long been broad bipartisan support for the idea that patients shouldn't have to pay additional, unexpected charges just because they needed emergency care or inadvertently received care from a provider outside their network, despite the fact that they had purposely chosen an in-network medical facility. There was disagreement, however, in terms of how these situations should be handled—should the insurer have to pay more, or should the out-of-network provider have to accept lower payments? This disagreement derailed numerous attempts at federal legislation to address surprise balance billing.

But the Consolidated Appropriations Act, 2021, which was enacted in December 2020, included broad provisions (known as the No Surprises Act) to protect consumers from surprise balance billing as of 2022. The law applies to both self-insured and fully-insured plans, including grandfathered plans, employer-sponsored plans, and individual market plans.

It protects consumers from surprise balance billing charges in nearly all emergency situations and situations when out-of-network providers offer services at in-network facilities, but there's a notable exception for ground ambulance charges.

This is still a concern, as ground ambulances are among the medical providers most likely to balance bill patients and least likely to be in-network, and patients typically have no say in what ambulance provider comes to their rescue in an emergency situation. But other than ground ambulances, patients are no longer subject to surprise balance bills as of 2022.

The No Surprises Act did call for the creation of a committee to study ground ambulance charges and make recommendations for future legislation to protect consumers. The Biden Administration announced the members of that committee in late 2022, and the committee began holding meetings in May 2023.

Balance billing continues to be allowed in other situations (for example, the patient simply chooses to use an out-of-network provider). Balance billing can also still occur when you’re using an in-network provider, but you’re getting a service that isn’t covered by your health insurance. Since an insurer doesn’t negotiate rates for services it doesn’t cover, you’re not protected by that insurer-negotiated discount. The provider can charge whatever they want, and you’re responsible for the entire bill.

It is important to note that while the No Surprises Act prohibits balance bills from out-of-network working at in-network facilities, the final rule for implementation of the law defines facilities as "hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers." Other medical facilities are not covered by the consumer protections in the No Surprises Act.

Balance billing doesn’t usually happen with in-network providers or providers that accept Medicare assignment . That's because if they balance bill you, they’re violating the terms of their contract with your insurer or Medicare. They could lose the contract, face fines, suffer severe penalties, and even face criminal charges in some cases.

If You Get an Unexpected Balance Bill

Receiving a balance bill is a stressful experience, especially if you weren't expecting it. You've already paid your deductible and coinsurance and then you receive a substantial additional bill—what do you do next?

First, you'll want to try to figure out whether the balance bill is legal or not. If the medical provider is in-network with your insurance company, or you have Medicare or Medicaid and your provider accepts that coverage, it's possible that the balance bill was a mistake (or, in rare cases, outright fraud).

And if your situation is covered under the No Surprises Act (ie, an emergency, or an out-of-network provider who treated you at an in-network facility), you should not be subject to a balance bill. So be sure you understand what charges you're actually responsible for before paying any medical bills.

If you think that the balance bill was an error, contact the medical provider's billing office and ask questions. Keep a record of what they tell you so that you can appeal to your state's insurance department if necessary.

If the medical provider's office clarifies that the balance bill was not an error and that you do indeed owe the money, consider the situation—did you make a mistake and select an out-of-network healthcare provider? Or was the service not covered by your health plan?

If you went to an in-network facility for a non-emergency, did you waive your rights under the No Surprises Act (NSA) and then receive a balance bill from an out-of-network provider? This is still possible in limited circumstances, but you would have had to sign a document indicating that you had waived your NSA protections.

Negotiate With the Medical Office

If you've received a legitimate balance bill, you can ask the medical office to cut you some slack. They may be willing to agree to a payment plan and not send your bill to collections as long as you continue to make payments.

Or they may be willing to reduce your total bill if you agree to pay a certain amount upfront. Be respectful and polite, but explain that the bill caught you off guard. And if it's causing you significant financial hardship, explain that too.

The healthcare provider's office would rather receive at least a portion of the billed amount rather than having to wait while the bill is sent to collections. So the sooner you reach out to them, the better.

Negotiate With Your Insurance Company

You can also negotiate with your insurer. If your insurer has already paid the out-of-network rate on the reasonable and customary charge, you’ll have difficulty filing a formal appeal since the insurer  didn’t actually deny your claim . It paid your claim, but at the out-of-network rate.

Instead, request a reconsideration. You want your insurance company to  reconsider the decision to cover this as out-of-network care , and instead cover it as in-network care. You’ll have more luck with this approach if you had a compelling medical or logistical reason for choosing an out-of-network provider .

If you feel like you’ve been treated unfairly by your insurance company, follow your health plan’s internal complaint resolution process.

You can get information about your insurer’s complaint resolution process in your benefits handbook or from your human resources department. If this doesn’t resolve the problem, you can complain to your state’s insurance department.

• Learn more about your internal and external appeal rights.
• Find contact information for your Department of Insurance using this resource .

If your health plan is self-funded , meaning your employer is the entity actually paying the medical bills even though an insurance company may administer the plan, then your health plan won't fall under the jurisdiction of your state’s department of insurance.

Self-funded plans are instead regulated by the Department of Labor’s Employee Benefit Services Administration. Get more information from the  EBSA’s consumer assistance web page  or by calling an EBSA benefits advisor at 1-866-444-3272.

If You Know You’ll Be Legally Balance Billed

If you know in advance that you’ll be using an out-of-network provider or a provider that doesn’t accept Medicare assignment, you have some options. However, none of them are easy and all require some negotiating.

Ask for an estimate of the provider’s charges. Next, ask your insurer what they consider the reasonable and customary charge for this service to be. Getting an answer to this might be tough, but be persistent.

Once you have estimates of what your provider will charge and what your insurance company will pay, you’ll know how far apart the numbers are and what your financial risk is. With this information, you can narrow the gap. There are only two ways to do this: Get your provider to charge less or get your insurer to pay more.

Ask the provider if he or she will accept your insurance company’s reasonable and customary rate as payment in full. If so, get the agreement in writing, including a no-balance-billing clause.

If your provider won’t accept the reasonable and customary rate as payment in full, start working on your insurer. Ask your insurer to increase the amount they’re calling reasonable and customary for this particular case.

Present a convincing argument by pointing out why your case is more complicated, difficult, or time-consuming to treat than the average case the insurer bases its reasonable and customary charge on.

Single-Case Contract

Another option is to ask your insurer to negotiate a  single-case contract   with your out-of-network provider for this specific service.

A single-case contract is more likely to be approved if the provider is offering specialized services that aren't available from locally-available in-network providers, or if the provider can make a case to the insurer that the services they're providing will end up being less expensive in the long-run for the insurance company.

Sometimes they can agree upon a single-case contract for the amount your insurer usually pays its in-network providers. Sometimes they’ll agree on a single-case contract at the discount rate your healthcare provider accepts from the insurance companies she’s already in-network with.

Or, sometimes they can agree on a single-case contract for a percentage of the provider’s billed charges. Whatever the agreement, make sure it includes a no-balance-billing clause.

Ask for the In-Network Coinsurance Rate

If all of these options fail, you can ask your insurer to cover this out-of-network care using your in-network coinsurance rate. While this won’t prevent balance billing, at least your insurer will be paying a higher percentage of the bill since your coinsurance for in-network care is lower than for out-of-network care.

If you pursue this option, have a convincing argument as to why the insurer should treat this as in-network. For example, there are no local in-network surgeons experienced in your particular surgical procedure, or the complication rates of the in-network surgeons are significantly higher than those of your out-of-network surgeon.

Balance billing refers to the additional bill that an out-of-network medical provider can send to a patient, in addition to the person's normal cost-sharing and the payments (if any) made by their health plan. The No Surprises Act provides broad consumer protections against "surprise" balance billing as of 2022.

A Word From Verywell

Try to prevent balance billing by staying in-network, making sure your insurance company covers  the services you’re getting, and complying with any pre-authorization requirements. But rest assured that the No Surprises Act provides broad protections against surprise balance billing.

This means you won't be subject to balance bills in emergencies (except for ground ambulance charges, which can still generate surprise balance bills) or in situations where you go to an in-network hospital but unknowingly receive care from an out-of-network provider.

Congress.gov. H.R.133—Consolidated Appropriations Act, 2021 . Enacted December 27, 2021.

Kona M. The Commonwealth Fund. State balance billing protections . April 20, 2020.

Data.CMS.gov. Opt Out Affidavits .

Chhabra, Karan; Schulman, Kevin A.; Richman, Barak D. Health Affairs. Are Air Ambulances Truly Flying Out Of Reach? Surprise-Billing Policy And The Airline Deregulation Act . October 17, 2019.

Kaiser Family Foundation. 2022 Employer Health Benefits Survey .

Centers for Medicare and Medicaid Services. Members of New Federal Advisory Committee Named to Help Improve Ground Ambulance Disclosure and Billing Practices for Consumers . December 13, 2022.

Centers for Medicare and Medicaid Services. Advisory Committee on Ground Ambulance and Patient Billing (GAPB) .

Internal Revenue Service; Employee Benefits Security Administration; Health and Human Services Department. Requirements Related to Surprise Billing . August 26, 2022.

National Conference of State Legislatures. States Tackling "Balance Billing" Issue . July 2017.

By Elizabeth Davis, RN Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.

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What is Medicare assignment and how does it work?

Kimberly Lankford,

​Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they’re accepting assignment.

A doctor who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. By comparison, a doctor who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.

That’s why it’s important to ask if a provider accepts assignment before you receive care, even if they accept Medicare patients. If a doctor doesn’t accept assignment, you will pay more for that physician’s services compared with one who does.

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How much do I pay if my doctor accepts assignment?

If your doctor accepts assignment, you will usually pay 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible. Because Medicare Part B covers doctor and outpatient services, your $240 deductible for Part B in 2024 applies before most coverage begins.

All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and will bill you the remaining 20 percent. You can get some preventive services and screenings, such as mammograms and colonoscopies , without paying a deductible or coinsurance if the provider accepts assignment. 

What if my doctor doesn’t accept assignment?

A doctor who takes Medicare but doesn’t accept assignment can still treat Medicare patients but won’t always accept the Medicare-approved amount as payment in full.

This means they can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive, called “balance billing.” In this case, you’re responsible for the additional charge, plus the regular 20 percent coinsurance, as your share of the cost.

How to cover the extra cost? If you have a Medicare supplement policy , better known as Medigap, it may cover the extra 15 percent, called Medicare Part B excess charges.

All Medigap policies cover Part B’s 20 percent coinsurance in full or in part. The F and G policies cover the 15 percent excess charges from doctors who don’t accept assignment, but Plan F is no longer available to new enrollees, only those eligible for Medicare before Jan. 1, 2020, even if they haven’t enrolled in Medicare yet. However, anyone who is enrolled in original Medicare can apply for Plan G.

Remember that Medigap policies only cover excess charges for doctors who accept Medicare but don’t accept assignment, and they won’t cover costs for doctors who opt out of Medicare entirely.

Good to know. A few states limit the amount of excess fees a doctor can charge Medicare patients. For example, Massachusetts and Ohio prohibit balance billing, requiring doctors who accept Medicare to take the Medicare-approved amount. New York limits excess charges to 5 percent over the Medicare-approved amount for most services, rather than 15 percent.

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How do I find doctors who accept assignment?

Before you start working with a new doctor, ask whether he or she accepts assignment. About 98 percent of providers billing Medicare are participating providers, which means they accept assignment on all Medicare claims, according to KFF.

You can get help finding doctors and other providers in your area who accept assignment by zip code using Medicare’s Physician Compare tool .

Those who accept assignment have this note under the name: “Charges the Medicare-approved amount (so you pay less out of pocket).” However, not all doctors who accept assignment are accepting new Medicare patients.

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What does it mean if a doctor opts out of Medicare?

Doctors who opt out of Medicare can’t bill Medicare for services you receive. They also aren’t bound by Medicare’s limitations on charges.

In this case, you enter into a private contract with the provider and agree to pay the full bill. Be aware that neither Medicare nor your Medigap plan will reimburse you for these charges.

In 2023, only 1 percent of physicians who aren’t pediatricians opted out of the Medicare program, according to KFF. The percentage is larger for some specialties — 7.7 percent of psychiatrists and 4.2 percent of plastic and reconstructive surgeons have opted out of Medicare.

Keep in mind

These rules apply to original Medicare. Other factors determine costs if you choose to get coverage through a private Medicare Advantage plan . Most Medicare Advantage plans have provider networks, and they may charge more or not cover services from out-of-network providers.

Before choosing a Medicare Advantage plan, find out whether your chosen doctor or provider is covered and identify how much you’ll pay. You can use the Medicare Plan Finder to compare the Medicare Advantage plans and their out-of-pocket costs in your area.

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

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What Is Medicare Assignment?

Written by: Rachael Zimlich, RN, BSN

Reviewed by: Eboni Onayo, Licensed Insurance Agent

Key Takeaways

Medicare assignment describes the fee structure that your doctor and Medicare have agreed to use.

If your doctor agrees to accept Medicare assignment, they agree to be paid whatever amount Medicare has approved for a service.

You may still see doctors who don’t accept Medicare assignment, but you may have to pay for your visit up front and submit a claim to Medicare for reimbursement.

You may have to pay more to see doctors who don’t accept Medicare assignment.

How Does Medicare Assignment Work?

What is Medicare assignment ?

Medicare assignment simply means that your provider has agreed to stick to a Medicare fee schedule when it comes to what they charge for tests and services. Medicare regularly updates fee schedules, setting specific limits for what it will cover for things like office visits and lab testing.

When a provider agrees to accept Medicare assignment, they cannot charge more than the Medicare-approved amount. For you, this means your out-of-pocket costs may be lower than if you saw a provider who did not accept Medicare assignment. The provider acknowledges that the amount Medicare set for a particular service is the maximum amount that will be paid.

You may still have to pay a Medicare deductible and coinsurance, but your provider will have to submit a claim to Medicare directly and wait for payment before passing any share of the costs onto you. Doctors who accept Medicare assignment cannot charge you to submit these claims.

Still have questions? GoHealth has the answers you need.

How Do I Know if a Provider Accepts Medicare Assignment?

There are a few levels of commitment when it comes to Medicare assignment.

• Providers who have agreed to accept Medicare assignment sign a contract with Medicare.
• Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers.
• Some providers opt out of Medicare altogether. Doctors who have opted out of Medicare completely or who use private contracts will not be paid anything by Medicare, even if it’s for a covered service within the fee limits. You will have to pay the full cost of any services provided by these doctors yourself.

You can check to see if your provider accepts Medicare assignment on Medicare’s website .

Billing Arrangement Options for Providers Who Accept Medicare

Doctors that take Medicare can sign a contract to accept assignment for all Medicare services, or be a non-participating provider that accepts assignment for some services but not all.

A medical provider that accepts Medicare assignment must submit claims directly to Medicare on your behalf. They will be paid the agreed upon amount by Medicare, and you will pay any copayments or deductibles dictated by your plan.

If your doctor is non-participating, they may accept Medicare assignment for some services but not others. Even if they do agree to accept Medicare’s fee for some services, Medicare will only pay then 95% of the set assignment cost for a particular service.

If your provider does plan to work with Medicare, either the provider or you can submit a claim to Medicare, but you may have to pay the entire cost of the visit up front and wait for reimbursement. They can’t charge you for more than the amount approved by Medicare, but they can charge you above the Medicare-approved amount. This is called the limiting charge, and can be up to 15% more than Medicare-approved amount for non-participating providers.

What Does It Mean When a Provider Does Not Accept Medicare Assignment?

Providers who refuse Medicare assignment can still choose to accept Medicare’s set fees for certain services. These are called non-participating providers.

There are a number of providers who opt out of participating in Medicare altogether; they are referred to as “opt-out doctors”. This means they have signed an opt-out agreement with Medicare and can’t be paid by Medicare at all — even for services normally covered by Medicare. Opt-out contracts last for at least two years. Some of these providers may only offer services to patients who sign contracts.

You do not need to sign a contract with a private provider or use an opt-out provider. There are many options for alternative providers who accept Medicare. If you do choose an opt-out or private contract provider, you will have to pay the full cost of services on your own.

What Medicare coverage is right for my specific situation?

Do providers have to accept Medicare assignment?

No. Providers can choose to accept a full Medicare assignment, or accept assignment rates for some services as a non-participating provider. Doctors can also opt out of participating in Medicare altogether.

How much will I have to pay if my provider doesn't accept Medicare assignment?

Some providers that don’t accept assignment as a whole will accept assignment for some services. These are called non-participating providers. For these providers and providers who have completely opted out of Medicare, you will pay the majority of or the full amount for your care.

How do I submit a claim?

If you need to submit your own claim to Medicare, you can call 1-800-MEDICARE or use Form CMS-1490S .

Can my provider charge to submit a claim?

No. Providers are not allowed to charge to submit a claim to Medicare on your behalf.

Lower Costs with Assignment. Medicare.gov.

Fee Schedules . CMS.gov.

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Office of the Assistant Secretary for Planning and Evaluation

Access to Physicians' Services for Medicare Beneficiaries

Key Findings:

-           According to federal survey data, the percentage of all office-based physicians who report accepting new Medicare patients has not changed significantly between 2005 and 2012, with 87.9% of physicians accepting new Medicare patients in 2005 and 90.7% in 2012.

-           The percentage of physicians who report accepting new Medicare patients is similar to, and in recent years slightly higher than, the percentage accepting new privately insured patients.

-           Medicare beneficiary access to care is high and has remained stable over the past five years.

Physician Participation in Medicare and Private Insurance

In order to assess trends in provider acceptance of Medicare and privately insured patients, the National Center for Health Statistics (NCHS) analyzed seven years of federal survey data from the National Ambulatory Medical Care Survey (NAMCS).  NAMCS is conducted by the NCHS of the Centers for Disease Control and Prevention, and is a nationally-representative survey of office-based M.D.s and D.O.s (Doctors of Medicine and Doctors of Osteopathy), excluding radiologists, anesthesiologists, and pathologists.  Data for 2005-2010 come from in-person interviews of physicians or office staff. [1]

The NAMCS data show that the percentage of physicians who report accepting new Medicare patients has remained stable over the past seven years, with approximately 90% of physicians accepting new Medicare patients (Figure 1).  Interim results from 2012 are based on a mail-survey, and data from in-person interviews will be available soon.  These initial data suggest that acceptance rates have increased slightly in 2012 from 2011.  For most of the 2005-2012 time period, the percentage of physicians accepting new privately insured patients is quite similar to the percentage accepting new Medicare patients, although evidence suggests the percentage accepting new Medicare patients may have increased slightly in 2011-12 while the percentage accepting new privately insured patients may have decreased slightly. [2]  

Figure 1: Percentage of Physicians Accepting New Patients with Medicare and Private Insurance, 2005-2012

Source: NCHS analysis of the 2005-2012 National Ambulatory Medical Care Survey (NAMCS)

According to Centers for Medicare and Medicaid Services (CMS) data, there were about 650,000 physicians who participated in the Medicare program in 2011 and nearly 1 million participating providers in total (including non-physician providers such as nurse practitioners). [3]   It is clear from the data in Figure 1 the percentage of all physicians who accept new Medicare patients has been stable from 2005 to 2012.  To the extent that there may have been a very small increase in the number of providers ‘opting out’, that increase has been mitigated by an increase in the share of other physicians who accept new Medicare patients.  Further, the total number of providers participating in and billing Medicare has steadily increased since 2007 (Figure 2).

Figure 2: Number of Providers Participating in and Billing Medicare, 2007-2011

Source: CMS Data Compendium, 2007-2011 editions, table VI.6

Note: Providers include MDs, DOs, limited license practitioners, and non-physician providers.

The data in Figure 1 and Figure 2 show that provider acceptance of new Medicare patients has been stable over the 2005 to 2012 period and the total number of providers participating in the program has increased.  These findings allay concern that the number of physicians ‘opting out’ of Medicare has increased in recent years. [4]    Physicians may opt out of the Medicare program for two years and establish written contracts with Medicare beneficiaries. Under these private contracts, beneficiaries are liable for payment of the care furnished. If a Medicare beneficiary receives services from a physician who has ‘opted out’, the beneficiary can pay the physician directly, but neither the physician nor the beneficiary receives any payment from Medicare. A 2005 study examining characteristics of providers opting out of Medicare found that overall less than one percent of providers eligible to opt out of Medicare did so, and the two specialties with the highest opt out percentages were psychiatrists (with 1.11% opting out) and plastic and reconstructive surgeons (with 1.56% opting out). [5]   In contrast, about a third of one percent of primary care physicians (0.35%) opted out of Medicare. 

Medicare Beneficiaries’ Access to Care

The extent to which providers participate in Medicare can affect beneficiaries’ access to timely, affordable care.  For example, if provider participation in Medicare were low, beneficiaries might face long waits for appointments or larger out-of-pocket payments for care.  However, based on multiple data sources, Medicare beneficiaries’ access to care appears to be excellent: it has been stable over the past five years and is comparable to or better than access reported by privately insured individuals.

Each year, the Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency which advises the U.S. Congress on issues affecting the Medicare program, assesses the adequacy of Medicare payments to physicians and other providers by evaluating beneficiary access to care, volume growth, quality of care, and Medicare’s payment rates relative to those in the private sector.   MedPAC conducts an annual survey of 4,000 Medicare beneficiaries and 4,000 privately insured individuals age 50-64 to evaluate access. [6]   In its March 2013 Report to Congress, based on this and other federal surveys, MedPAC noted that Medicare beneficiaries report good access to care, and access to physicians’ services has remained stable over the past five years (Table 1). [7]   For example, in 2012, 77% of Medicare beneficiaries reported they never experienced an unwanted delay in getting an appointment for routine care, compared with 76% in 2008.  These results are similar to the reports provided by people with private insurance in the MedPAC survey.  Similarly, the large majority of beneficiaries had no problems getting an appointment with a new physician, and again the results are comparable to those for people with private insurance.   Additionally, Medicare beneficiaries were less likely than the privately insured to report forgoing needed medical care (8% vs. 11%) in 2012.

These findings are consistent with other national surveys.  For example, data from the 2010 Medicare Current Beneficiary Survey (MCBS) indicate that 95% of beneficiaries had a usual source of medical care.  Nearly half of all beneficiaries seeking an appointment with a provider were able to see a provider within three days.  About five percent of beneficiaries had trouble getting needed care.  Similarly, the 2011 National Health Interview Survey (NHIS) included several questions on problems with access to care.  Overall, access problems among Medicare beneficiaries were low and comparable to the privately insured (Table 2).

Table 2: Access Problems among Medicare and Privately Insured, 2011-2012

Source: NCHS analysis of the 2011 National Health Interview Survey

Additionally, data from the Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (FFS CAHPS) survey suggest that there has been a slight increase in FFS beneficiaries’ access to care (Figure 3).  The percentage of FFS Medicare beneficiaries reporting that they always were able to receive needed care  from a specialist increased between 2008 and the first quarter of 2013 (from 61% to 66%).  Similarly, the percentage of FFS Medicare beneficiaries reporting that they always were able to get care for an illness or injury when they thought they needed it increased slightly between 2008 and the first quarter of 2013 (from 69% to 71%), as did the percentage who reported always being able to get an appointment for regular or routine health care when needed (61% to 62%).

Figure 3: Fee-for-Service Beneficiaries’ Access to Care, 2008-2013

Source: CMS and ASPE analysis of 2008-2013 FFS CAHPS data

Notes: All items have four response categories rated 1-4, where 1 is “never” and 4 is “always”.

Approximately 90% of all office-based physicians report accepting new Medicare patients.   The percentage of physicians who report accepting new Medicare patients is similar to the percentage of physicians who report accepting new privately insured patients.  In addition, the share accepting new Medicare patients has been relatively stable over the 2005-2012 period and shows a slight increase in 2011-2012 based on initial NAMCS data.  Beneficiary reports of access to care, including the ability to find a physician and see a doctor in a timely manner, are also favorable.  Again, these results are comparable to reports by patients with private insurance and have been stable over time.  Overall, Medicare beneficiary access to care has been consistently high over the last decade and continues to be high today.

Acknowledgments

The authors would like to thank Sandy Decker at the National Center for Health Statistics for her assistance with the NAMCS and NHIS data estimates and Elizabeth Goldstein at the Centers for Medicare & Medicaid Services for her assistance with the FFS-CAHPS data analysis.  We also would like to thank HHS staff for their comments.

[1] 2011 data come from the NAMCS Electronic Records Supplement and 2012 from the NAMCS Electronic Health Records Survey, both conducted by mail. Unweighted response rates were between 58-67% depending on the year. Estimates used sample weights to yield nationally-representative estimates, and standard errors accounted for the complex survey design. Estimates excluded pediatricians and any respondent missing information on either acceptance of new Medicare or privately insured patients. Respondents missing information on acceptance of both ranged from 6-12%, depending on the year.

[2] Based on the NAMCS, pr imary care physicians (PCPs) and other specialties have similar trends of acceptance rates. PCPs are slightly less likely to accept new patients with either Medicare or private insurance than other specialties, but most physicians accept new patients of either insurance type. The percentage accepting new Medicare patients has been stable over the last decade, with about 85% of PCPs and 90% of other specialties accepting new Medicare patients. PCPs show an increase in acceptance rates (87.4%) in 2012; the increase for other specialties to 92.4% was not statistically significant.

[3] Medicare participating providers agree to accept “assignment” (the full Medicare payment rate) for services.  Non-participating providers can accept assignment or can choose to be reimbursed by Medicare at 95% of the Medicare rate for participating providers with the ability to balance bill beneficiaries up to 115% of the non-participating provider rate.  The sum of these two categories is shown in the “billing” column.  Those providers who completely opt-out do not receive any reimbursements from Medicare, even for covered services.

[4] Beck, M. “More Doctors Steer Clear of Medicare”, Wall Street Journal 7/29/13 p.A1, vCCLXII #24.  This article reported that the number of physicians opting out of Medicare increased from 3,700 in 2009 to 9,539 in 2012.

[5] Buczko, W (2005). “Provider Opt-out Under Medicare Private Contracting,” Health Care Financing Review 26(2):43-59.

[6] The MedPAC survey includes all Medicare beneficiaries and does not distinguish Medicare FFS enrollees from those in Medicare Advantage (MA) plans because of the technical difficulty in obtaining reliable self-identification of FFS or MA enrollment from surveyed individuals.

[7] Medicare Payment Advisory Commission (MedPAC), “Report to the Congress: Medicare Payment Policy,” Chp. 4, March 2013.

Medicare Options

To help ensure that physicians are making informed decisions about their contractual relationships with the Medicare program, the AMA has developed a “Medicare Participation Kit”(www.ama-assn.org) that explains the various participation options that are available to physicians. A summary of those options is presented below. The AAFP is not advising or recommending any of the options. The purpose of sharing this information is merely to ensure that physician decisions about Medicare participation are made with complete information about the available options. Please note that the summary below does not account for any payment adjustments that a participating or non-participating physician may incur through one of the Medicare initiatives, such as the Physician Quality Reporting System. Physicians wishing to change their Medicare participation or non-participation status for a given year are usually required to do so by December 31 of the prior year (e.g., December 31, 2015 for 2016). Participation decisions are effective January 1 of the year in question and are binding for the entire year.

The Three Options

There are basically three Medicare contractual options for physicians. Physicians may sign a participating (PAR) agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients. They may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Or they may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves. Physicians who wish to change their status from PAR to non-PAR or vice versa may do so annually. Once made, the decision is generally binding until the next annual contracting cycle except where the physician's practice situation has changed significantly, such as relocation to a different geographic area or a different group practice. To become a private contractor, physicians must give 30 days notice before the first day of the quarter the contract takes effect. Those considering a change in status should first determine that they are not bound by any contractual arrangements with hospitals, health plans or other entities that require them to be PAR physicians. In addition, some states have enacted laws that prohibit physicians from balance billing their patients.

Participation

PAR physicians agree to take assignment on all Medicare claims, which means that they must accept Medicare's approved amount (which is the 80% that Medicare pays plus the 20% patient copayment) as payment in full for all covered services for the duration of the calendar year. The patient or the patient's secondary insurer is still responsible for the 20% copayment but the physician cannot bill the patient for amounts in excess of the Medicare allowance. While PAR physicians must accept assignment on all Medicare claims, however, Medicare participation agreements do not require physician practices to accept every Medicare patient who seeks treatment from them.

Medicare provides a number of incentives for physicians to participate:

• The Medicare payment amount for PAR physicians is 5% higher than the rate for non-PAR physicians.
• Directories of PAR physicians are provided to senior citizen groups and individuals who request them.
• Medicare administrative contractors (MAC) provide toll-free claims processing lines to PAR physicians and process their claims more quickly.

Non-Participation

Medicare approved amounts for services provided by non-PAR physicians (including the 80% from Medicare plus the 20% copayment) are set at 95% of Medicare approved amounts for PAR physicians, although non-PAR physicians can charge more than the Medicare approved amount.

Limiting charges for non-PAR physicians are set at 115% of the Medicare approved amount for non-PAR physicians. However, because Medicare approved amounts for non-PAR physicians are 95% of the rates for PAR physicians, the 15% limiting charge is effectively only 9.25% above the PAR approved amounts for the services. Therefore, when considering whether to be non-PAR, physicians must determine whether their total revenues from Medicare, patient copayments and balance billing would exceed their total revenues as PAR physicians, particularly in light of collection costs, bad debts and claims for which they do accept assignment. The 95% payment rate is not based on whether physicians accept assignment on the claim, but whether they are PAR physicians; when non-PAR physicians accept assignment for their low-income or other patients, their Medicare approved amounts are still only 95% of the approved amounts paid to PAR physicians for the same service. Non-PAR physicians would need to collect the full limiting charge amount roughly 35% of the time they provided a given service in order for the revenues from the service to equal those of PAR physicians for the same service. If they collect the full limiting charge for more than 35% of the services that they provide, their Medicare revenues will exceed those of PAR physicians.

Assignment acceptance, for either PAR or non-PAR physicians, also means that the MAC pays the physician the 80% Medicare payment. For unassigned claims, even though the physician is required to submit the claim to Medicare, the program pays the patient, and the physician must then collect the entire amount for the service from the patient.

Example: A service for which Medicare fee schedule amount is $100

Private contracting.

Provisions in the Balanced Budget Act of 1997 give physicians and their Medicare patients the freedom to privately contract to provide health care services outside the Medicare system. Private contracting decisions may not be made on a case-by-case or patient-by-patient basis, however. Once physicians have opted out of Medicare, they cannot submit claims to Medicare for any of their patients for a two-year period.

A physician who has not been excluded under sections 1128, 1156 or 1892 of the Social Security Act may, however, order, certify the need for, or refer a beneficiary for Medicare-covered items and services, provided the physician is not paid, directly or indirectly, for such services (except for emergency and urgent care services). For example, if a physician who has opted out of Medicare refers a beneficiary for medically necessary services, such as laboratory, DMEPOS or inpatient hospitalization, those services would be covered by Medicare.

To privately contract with a Medicare beneficiary, a physician must enter into a private contract that meets specific requirements, as set forth in the sample private contract below. In addition to the private contract, the physician must also file an affidavit that meets certain requirements, as contained in the sample affidavit below. To opt out, a physician must file an affidavit that meets the necessary criteria and is received by the MAC at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.

Emergency and Urgent Care Services Furnished During the "Opt-Out" Period

Physicians who have opted-out of Medicare under the Medicare private contract provisions may furnish emergency care services or urgent care services to a Medicare beneficiary with whom the physician has previously entered into a private contract so long as the physician and beneficiary entered into the private contract before the onset of the emergency medical condition or urgent medical condition. These services would be furnished under the terms of the private contract.

Physicians who have opted-out of Medicare under the Medicare private contract provisions may continue to furnish emergency or urgent care services to a Medicare beneficiary with whom the physician has not previously entered into a private contract, provided the physician:

• Submits a claim to Medicare in accordance with both 42 CFR part 424 (relating to conditions for Medicare payment) and Medicare instructions (including but not limited to complying with proper coding of emergency or urgent care services furnished by physicians and qualified health care professionals who have opted-out of Medicare).
• Collects no more than the Medicare limiting charge, in the case of a physician (or the deductible and coinsurance, in the case of a qualified health care professional).

Note that a physician who has been excluded from Medicare must comply with Medicare regulations relating to scope and effect of the exclusion (42 C.F.R. § 1001.1901) when the physician furnishes emergency services to beneficiaries, and the physician may not bill and be paid for urgent care services.

Sample Medicare Private Contract and Affidavit

The sample private contract and affidavit below contain the provisions that Medicare requires (unless otherwise noted) to be included in these documents.

Private contracts must meet specific requirements:

• The physician must sign and file an affidavit agreeing to forgo receiving any payment from Medicare for items or services provided to any Medicare beneficiary for the following 2-year period (either directly, on a capitated basis or from an organization that received Medicare reimbursement directly or on a capitated basis).
• Medicare does not pay for the services provided or contracted for. The contract must be in writing and must be signed by the beneficiary before any item or service is provided.
• The contract cannot be entered into at a time when the beneficiary is facing an emergency or an urgent health situation.

In addition, the contract must state unambiguously that by signing the private contract, the beneficiary:

• gives up all Medicare payment for services furnished by the "opt out" physician;
• agrees not to bill Medicare or ask the physician to bill Medicare;
• is liable for all of the physician's charges, without any Medicare balance billing limits;
• acknowledges that Medigap or any other supplemental insurance will not pay toward the services; and acknowledges that he or she has the right to receive services from physicians for whom Medicare coverage and payment would be available.

If you determine that you want to "opt out" of Medicare under a private contract, we recommend that you consult with your attorney to develop a valid contract containing other standard non-Medicare required provisions that generally are included in any standard contract.

Download sample contracts:

• Sample Medicare Private Contract
• Sample Medicare Private Contracts "Opt-Out" Affidavit

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If you have Original Medicare , your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of provider, meaning three different relationships a provider can have with Medicare . A provider’s type determines how much you will pay for Part B -covered services.

• These providers are required to submit a bill (file a claim ) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem .
• If you see a participating provider , you are responsible for paying a 20% coinsurance for Medicare-covered services.
• Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
• Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge ). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
• Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP) .
• If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount .
• The limiting charge rules do not apply to durable medical equipment (DME) suppliers . Be sure to learn about the different rules that apply when receiving services from a DME supplier .
• Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
• The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
• Opt-out providers do not bill Medicare for services you receive.
• Many psychiatrists opt out of Medicare.

Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date you received care. If your provider misses the filing deadline, they cannot bill Medicare for the care they provided to you. However, they can still charge you a 20% coinsurance and any applicable deductible amount.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool .

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Most Office-Based Physicians Accept New Patients, Including Patients With Medicare and Private Insurance

Nancy Ochieng , Matthew Rae , Jeannie Fuglesten Biniek , and Tricia Neuman Published: May 12, 2022

Over the past decade, health care prices paid by private insurers have risen sharply. These higher prices contribute to higher health care costs per person, which contribute to higher premiums and out-of-pocket spending among the privately insured. In contrast to Medicare, which pays physicians based on a fee schedule, prices for those with private insurance are negotiated by payers and providers, and on average, private insurers pay 143% more for physician services than Medicare. The difference in Medicare and private prices has served as the basis for proposals to adopt Medicare rates, or a multiple of Medicare rates, for those with private insurance, or as part of a Medicare-like plan through a public option or single payer plan.

Over the years, some have questioned whether the level of Medicare payments for physicians are too low to cover the costs of providing care and have raised concerns that moving towards Medicare rates would cause access problems. Previous KFF analysis has found that even though Medicare payments to physicians are lower, the vast majority of Medicare beneficiaries report having a usual source of care and high levels of satisfaction with the quality of their medical care. In addition, two separate KFF analyses, using data from 2012-2013 and 2020 , found that the nearly all physicians accept Medicare, and only a small fraction “opt out” of Medicare altogether.

This brief builds on and updates the previous KFF analyses by drawing on the 2019 National Electronic Health Records Survey (NEHRS) to examine: 1) the share of non-pediatric office-based physicians accepting new patients with Medicare or private insurance and how these rates have changed over time; and 2) the share of physicians accepting new patients by physician specialties, geographic areas, and physician and practice characteristics across Medicare and private insurance. We are only able to assess whether doctors report accepting any new patients and cannot evaluate whether all new patients are accepted or how timely or convenient it is to schedule an appointment. This analysis further examines the extent to which non-pediatric physicians are opting out of Medicare, by specialty and state, drawing on 2022 opt-out affidavit data published by the Centers for Medicare & Medicaid services and data on the total number of active state-licensed physicians from Redi-Data, Inc ( See Methods box for details ).

Key findings include:

• Across almost every dimension we examine, the share of physicians accepting new Medicare patients is similar to the share accepting new patients with private insurance, with the only exception being the share of obstetricians and gynecologists accepting new Medicare patients (93%) is somewhat lower than the share accepting new privately-insured patients (99%). Physicians accepting new patients with private insurance will not be participating in every plan’s network, and similarly will not be in every Medicare Advantage plan network.
• Most non-pediatric office-based physicians accept new Medicare patients (89%), as well as new private insurance patients (91%).
• In 2011 and 2019, 88% and 89% of non-pediatric office-based physicians accepted new Medicare patients, respectively, with modest fluctuations in the years in between. The share accepting new patients with private insurance increased by 10 percentage points over the period, rising from 81% in 2011 to 91% in 2019, a share similar to Medicare.
• Across most specialties, the majority of physicians (at least 80%) accept new patients with Medicare and private insurance. Almost all surgical specialists accept new Medicare and privately-insured patients (96% for both). Among primary care physicians the rates are lower, but comparable for new patients with Medicare (83%) and private insurance (86%), similar to the share of physicians in other medical specialties accepting new Medicare (87%) and privately-insured (88%) patients. The share of physicians accepting new patients is lowest among psychiatrists with 60% accepting new Medicare patients and 59% accepting new privately-insured patients.
• In 23 states, at least 90% of all non-pediatric office-based physicians accepted new Medicare patients in 2015-2017. Across states, the share of physicians accepting new Medicare patients ranged from a high of 95% in three states (Iowa, Minnesota, and Pennsylvania) to a low of 76% in the District of Columbia, similar to the range across states for privately-insured patients.
• A very small (1%) share of non-pediatric physicians formally opted-out of the Medicare program in 2022, with psychiatrists accounting for a disproportionate share of physicians opting-out. In all states except for Alaska and Colorado, less than 2% of physicians have opted-out of Medicare.

Acceptance of new patients by office-based physicians by type of insurance coverage

Differences in payment rates may affect whether people with different types of insurance coverage have comparable access to physician services. We use data from the National Electronic Health Records Survey (NEHRS) for 2011 to 2019 (the most recent year of data) to assess whether there are differences in the share of non-pediatric office-based physicians who are accepting new patients across Medicare and private insurance.

The vast majority of non-pediatric office-based physicians accept new patients, with similar shares accepting new Medicare and privately-insured patients. Overall, 95% of office-based physicians accepted new patients in 2019. The share of physicians accepting new patients was similar for Medicare (89%) and private insurance (91%), with no statistically significant differences between the payers (Figure 1). The share of physicians accepting any new patients is higher than the share accepting Medicare or private insurance because some physicians only accept patients with one type of insurance but not others, including types of insurance not broken out here (i.e., self-pay patients).

Between 2011 and 2019 the overall share of non-pediatric office-based physicians accepting new patients was stable and a consistent share accepted new Medicare patients. In 2011 and 2019, 88% and 89% of office-based physicians accepted new Medicare patients, respectively, with modest fluctuations in the years in between. During this same period, the share of physicians accepting new privately-insured patients increased from 81% in 2011 to 91% in 2019, becoming more similar to the share that accepted new Medicare patients (Figure 1).

Share of physicians accepting new Medicare and privately-insured patients, by specialty

To understand whether access varies more for some types of physicians, we examine whether the share of physicians accepting new patients is different for primary care, medical and surgery specialty groups, and among 12 common specialties.

A smaller share of primary care physicians accept new Medicare or privately-insured patients than physicians in other medical or surgical specialties. To look at differences by specialty type, we pooled 2017 and 2019 NHERS survey data. Overall, a smaller share of primary care physicians (89%) reported having an open practice—meaning they accept any new patients—compared to other medical specialists (95%) and surgical specialists (99%). This pattern was consistent across Medicare and private insurance. A smaller share of primary care physicians accepted new Medicare (83%) or privately insured patients (86%), while the vast majority of surgical specialists accepted new patients with either type of insurance (96% for both). Among other medical specialists, 87% were accepting new Medicare patients and 88% were accepting new privately-insured patients (Table 1).

In most specialties, similar shares of physicians accept new Medicare and privately-insured patients . Except for obstetrics and gynecology, there were no statistically significant differences in the share of physicians accepting new patients with Medicare and private insurance. A larger share of obstetricians and gynecologists accepted new privately-insured patients (99%) than new Medicare patients (93%) (Figure 2, Table 1). Notably, almost 1 in 5 of general/family practice and internal medicine physicians were not taking new Medicare patients, similar to the share not taking new privately-insured patients.

Figure 2: In Most Specialties, The Shares of Physicians Accepting New Patients With Medicare and Private Insurance Are Similar

Among all non-pediatric, office-based physicians, psychiatrists were least likely to accept new patients regardless of insurance type . Among psychiatrists, similar shares were accepting new Medicare (60%) and privately-insured (59%) patients (Figure 2, Table 1). For both Medicare and private insurance, the share of psychiatrists accepting new patients was at least 20 percentage points lower than the share of physicians in general/family practice accepting new patients.

Variation in acceptance of new patients across states, in counties that have provider shortages, and by metropolitan status

To understand whether access to physician services varies geographically, we examined the share of office-based physicians accepting new patients by state, metropolitan status, as well as for counties that are designated as primary care or mental health professional shortage areas (HPSAs). Examining whether the share of physicians accepting new Medicare or privately-insured patients varies in HPSA designated counties highlights how differences in payment rates interacts with the supply of providers to affect access to physician services.

state-level shares of physicians accepting new patients

In every state, a large majority of non-pediatric office-based physicians accept new Medicare patients, with some variation among states. In 23 states, at least 90% of physicians accepted new Medicare patients (Figure 3). The five states with the highest share of physicians accepting new Medicare patients were Iowa (95%), Minnesota (95%), Pennsylvania (95%), South Carolina (95%), and North Dakota (94%). The states with the smallest share of physicians accepting new Medicare patients were the District of Columbia (76%), Utah (79%), Oregon (79%), Hawaii (79%), and Maryland (80%). This pattern was generally similar for privately-insured patients, where the share of physicians accepting new patients ranged from 96% (Arkansas) to 72% (the District of Columbia).

county and rural status variation

The Health Resources and Services Administration (HRSA) designates counties as primary care and/or mental health professional shortage areas (HPSAs) if the availability of providers or services is lower than necessary to support the population’s needs. When a county is designated as a HPSA, there are additional incentives for health care professionals to provide services, including a 10 percent bonus payment for providing care to Medicare beneficiaries and eligibility for special federal and state student loan repayment programs for providers that accept Medicare, Medicaid and CHIP patients in these areas. We examine whether the lower supply of providers in HPSA-designated areas is correlated with fewer physicians accepting new patients.

The vast majority of physicians in counties with primary care or mental health shortages accept new Medicare patients, with similar rates for privately-insured patients. In counties where the whole county is designated as a primary care HPSA, 89% of physicians accepted new Medicare patients and 91% of physicians accepted new privately-insured patients. Similarly, in mental health HPSAs, most physicians accepted both new Medicare (89%) and privately-insured (90%) patients. While the share of physicians in these areas accepting new patients is generally high, access can still be problematic since there are not enough physicians available in these areas to provide care.

Most (89%) physicians practicing in rural areas accept new Medicare patients, similar to the share of physicians accepting new privately-insured patients (91%). The share of physicians accepting new patients were similar across Medicare and private insurance in both rural and urban areas (Table 1).

Variation in acceptance of new patients by physician and practice characteristics

The composition of physicians is changing as more women enter medicine , the share of physicians who hold a Doctor of Osteopathic Medicine (DO) rather than a Doctor of Medicine (MD) is increasing , and doctors practice medicine longer, raising the average age of physicians in the United States. Additionally, physicians are increasingly practicing as part of large or multi-specialty groups , rather than in solo or small practice settings. As the composition of the physician workforce and how physicians practice changes, understanding the relationship between physician and practice characteristics and the acceptance of new patients, and whether this varies by payer, is helpful in assessing how access to physician services may evolve over time. We examine physician acceptance rates by physician characteristics (age, sex, degree type) and practice characteristics (group size, group setting), using 2017 and 2019 pooled data from the NEHRS.

The share of physicians accepting new Medicare patients was generally similar across physician demographic groups, but younger physicians were more likely to take new patients. There were no statistically significant differences in the share of physicians accepting new patients between Medicare and private insurance by physician age, sex or degree type (Table 1). Across both Medicare and private insurance, physicians who were younger than age 65 were more likely than physicians ages 65 and older to take new patients, with 89% and 91% of physicians under age 65 accepting new Medicare and privately-insured patients, respectively, compared to 82% and 84% of physicians age 65 and over. A similar trend was evident for physicians younger than age 50 compared to physicians ages 50 and older. There were no statistically significant differences within insurance groups by physician sex or degree type.

Solo practicing physicians were least likely to report that they were accepting new patients with both Medicare and private insurance. The share of physicians accepting new Medicare and privately-insured patients was similar when comparing by the size and practice type. By group size, a smaller share of physicians in solo practices accepted new Medicare (81%) or privately-insured (83%) patients than in practices with 2 physicians (89% for Medicare, 92% for privately-insured), 3-5 physicians (91% for Medicare, 94% for privately insured), and 6-10 physicians (92% for Medicare, 93% for privately-insured). Additionally, a smaller share of physicians in solo practices accepted new privately-insured patients (83%) than physicians in practices with or 11 or more physicians (87% for Medicare, 89% for privately-insured); however, differences between physicians in solo practices and physicians in practices with 11 or more physicians were not statistically significant for new Medicare patients.

A larger share of physicians in multispecialty group practices accepted new Medicare (90%) patients compared to physicians in single-specialty practices (86%) (Table 1, Figure 4). Differences between Medicare and privately-insured patients and between single- and multi-specialty practices for private insurance were not statistically significant.

Figure 4: A Smaller Share of Physicians in Solo Practices Accept New Medicare Patients Than Physicians in Multi-Specialty or Larger Group Practices

Physician Opt-Out Rates in the Medicare Program

Physicians and other health providers may participate in Medicare by either 1) agreeing to accept Medicare’s fee schedule amounts as payment-in-full (i.e., participating providers) or 2) accepting Medicare patients but choosing whether to accept Medicare’s approved amount on a claim-by-claim basis (i.e., non-participating providers). Physicians can also choose to “opt-out” of the Medicare program entirely by submitting an opt-out affidavit to Medicare. Physicians who have opted-out of Medicare enter into private contracts with their Medicare patients, allowing them to bill their Medicare patients any amount they deem appropriate and Medicare patients are responsible for the entire cost of these services. Prior KFF analyses found that a historically small share of physicians have chosen to opt-out of Medicare entirely. Our analysis examines the extent to which non-pediatric physicians are opting-out of Medicare, by specialty, and by state. We use opt-out affidavit data from the Centers for Medicare & Medicaid services as of March 2022. To calculate the total number of active state-licensed physicians, we draw January 2022 data from Redi-Data, Inc.

Only 1% of all non-pediatric physicians have formally opted-out of the Medicare program in 2022, with opt-rates varying by specialty, and highest for psychiatrists (7.5%). As of March 2022, 10,105 non-pediatric physicians have opted-out of Medicare, accounting for a very small share (1.0%) of the total number of active physicians, consistent with the shares reported in 2013 and 2020 . Opt-out rates vary by specialty and are highest for psychiatrists (7.5%), physicians in plastic and reconstructive surgery (3.8%), and neurology (2.9%) (Figure 5). Among the 10,105 physicians opting out of Medicare, psychiatrists account for 42% of these physicians.

In all but two states (Alaska, Colorado), less than 2 percent of non-pediatric physicians have opted-out of Medicare . As of March 2022, Alaska (3.3%), Colorado (2.2%), District of Columbia (1.9%), Wyoming (1.9%), and Idaho (1.9%) have the highest rates of non-pediatric physicians who have opted out of Medicare. States with the lowest physician opt-out rates include North Dakota (0.1%), West Virginia (0.1%), South Dakota (0.2%), Nebraska (0.3%), and Minnesota (0.4%).

Our analysis finds that the vast majority of non-pediatric office-based physicians accept new patients. We also find that the share accepting new Medicare patients largely mirrors the share accepting new privately-insured patients, despite higher payments from private insurers relative to Medicare . This suggests that Medicare’s relatively lower payment rates for physician services do not generally lead to fewer physicians accepting new Medicare patients. We note, however, that due to data limitations we were unable to differentiate the extent to which physicians accepting new patients are accepting all, most, or just some new patients, or the timeliness of getting appointments and needed care. We also cannot assess how many physicians participate in any or all private insurance or Medicare Advantage networks, or the impact of concierge medicine on patients’ access to physician services.

The high share of non-pediatric, office-based physicians accepting new patients – both Medicare and privately insured – was consistent across most specialties, geographic areas, and physician and practice characteristics. Increasingly, hospitals are acquiring medical practices and providing more services in a hospital setting. Due to data limitations, we are unable to assess how these trends may affect access to physician services, either overall or for patients with different types of insurance.

Notably, psychiatrists are significantly less likely than other physicians to accept new patients with either Medicare or private insurance. This finding does not suggest that Medicare rates specifically contribute to access problems for beneficiaries, but it does raise a concern about access to psychiatrists and potentially other mental health practitioners, an issue that was likely exacerbated by the COVID-19 pandemic with the increase in the share of adults reporting symptoms of anxiety disorder and/or depressive disorder.

Despite concerns that lower physician fees paid by Medicare relative to fees paid by private insurance may disincentivize physicians from taking Medicare patients, our analysis suggests that Medicare beneficiaries continue to have good access to physicians, similar to people with private insurance.

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news release

• Analysis: The Vast Majority of Physicians Accept New Patients, Including Patients With Medicare and Private Insurance

Also of Interest

• How Many Physicians Have Opted Out of the Medicare Program?
• What to Know About How Medicare Pays Physicians
• FAQs on Mental Health and Substance Use Disorder Coverage in Medicare