Ethan Rhodes
Medicare provides health insurance coverage to 67 million adults, or 20% of the US population, and is a significant source of revenue for physicians and other healthcare providers. While most hospitals accept Medicare, some may not. Generally, the hospitals that do not accept Medicare are VA hospitals and active military hospitals, which operate with veterans' and military benefits instead. There are also a few other exceptions nationwide, including some public hospitals. Hospitals that accept Medicare must meet certain requirements, including complying with federal, state, and local laws, having a governing body that is legally responsible for the hospital's conduct, and protecting patient rights.
| Characteristics | Values |
|---|---|
| Hospitals that do not accept Medicare | VA hospitals and active military hospitals |
| Reason for non-acceptance | They operate with veterans and military benefits |
| Other hospitals that do not accept Medicare | Some public hospitals |
| Hospitals that accept Medicare | The vast majority of hospitals accept Original Medicare (Parts A and B) |
| Medicare Advantage Plan | Also known as Medicare Part C or MA Plan |
| Medicare Advantage Plan providers | Medicare-approved private insurance companies |
| Medicare Advantage Plan coverage | All services under Original Medicare and may also provide additional coverage |
| Medicare beneficiaries enrolled in a Medicare Advantage Plan | Not required to pay the Part A and Part B deductibles separately |
| Hospitals that do not accept Medicare Advantage Plans | Some hospitals |
| Medicare providers | Doctors or other healthcare providers |
| Medicare providers that accept assignment | Most providers |
| Medicare providers that do not accept assignment | May charge more than the Medicare-approved amount |
| Opt-out physicians | 1.2% of active physicians |
| Physicians who opt out | Psychiatrists, physicians in family medicine, internal medicine, obstetrics/gynecology |
| Non-physician providers that opt out | Oral surgeons, podiatrists, optometrists |
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What You'll Learn
Hospitals that don't accept Medicare
Medicare provides health insurance coverage to 67 million adults, which is about 20% of the US population. It is a significant source of revenue for physicians and other healthcare providers. While most hospitals accept Medicare, some may not. Generally, the hospitals that do not accept Medicare are Veterans Affairs (VA) and active military hospitals because they operate with VA and military benefits. However, there are a few other exceptions to this rule across the country.
Hospitals that do not accept Medicare are not required to participate in the program. Participation is voluntary. However, there are certain factors that can make it difficult for hospitals to opt out of this participation. For instance, not-for-profit hospitals are required to care for Medicare beneficiaries because they receive federal tax exemptions for providing healthcare. Additionally, around 60% of all care provided in hospitals is for Medicare or Medicaid beneficiaries.
Physicians and other healthcare providers who do not want to work with the Medicare program may "opt out" of it. To do so, they must sign an "opt-out" agreement with their patients. Medicare won't pay for items or services received from providers who opt out, except in emergencies. Opt-out physicians and other practitioners must sign an affidavit to "opt out" of the Medicare program entirely. These providers enter into private contracts with their Medicare patients, allowing them to bill any amount they deem appropriate.
Medicare beneficiaries seeing a participating provider can only be liable for the cost-sharing required by Medicare. Providers have several incentives to be participating providers, such as being paid higher rates (5% higher) than the rates paid to non-participating providers. Non-participating providers accept Medicare patients but can choose whether to take assignment (i.e., Medicare's approved amount) on a claim-by-claim basis. Unlike participating providers, who are paid the full Medicare-allowed payment amount, non-participating physicians who take assignment are limited to 95% of the Medicare-approved amount.
To be certain that your local or preferred hospital accepts Medicare, visit Medicare.gov's Health Care Comparison tool. This tool allows you to search for hospitals, doctors, nursing homes, hospice care, long-term facilities, and dialysis centres that accept Medicare. Additionally, you can use the Medicare online tool to find hospitals in your area that accept Medicare.
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Medicare Advantage Plans
Before enrolling in a Medicare Advantage Plan, it is advisable to consult with your employer, union, or benefits administrator to understand their rules and any potential impact on your existing coverage. Additionally, you can use online tools provided by Medicare to find specific cost information about different Medicare Advantage Plans and determine which hospitals accept Medicare near you.
While most hospitals accept Medicare, there are some exceptions. Generally, VA hospitals and active military hospitals do not accept Medicare, as they operate with veterans and military benefits. However, not-for-profit hospitals are required to care for Medicare beneficiaries due to their federal tax exemptions for providing healthcare. It's always a good idea to check if your preferred hospital accepts Medicare and be aware of any out-of-pocket costs associated with your visit.
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Providers opting out of Medicare
While most hospitals accept Medicare, some may not. Generally, the hospitals that do not accept Medicare are Veterans Affairs and active military hospitals because they operate with VA and military benefits instead. However, there are a few other exceptions nationwide. Hospitals need to follow specific safety and health regulations to participate with Medicare.
Doctors or other healthcare providers who don't want to work with the Medicare program may "opt out" of Medicare. Medicare won't pay for items or services received from providers who opt out, except in emergencies. Providers who opt out of Medicare enter into private contracts with Medicare beneficiaries, allowing them to set their own fees. If a provider chooses to opt out, they must do so for a minimum of two years. Every two years, the provider can choose to keep their opt-out status, accept Medicare-approved amounts on a case-by-case basis ("non-participating"), or accept assignment.
If you choose to get services from an opt-out doctor or provider, you may need to pay upfront or set up a payment plan with the provider through a private contract. Medicare won't pay for any service you get from an opt-out doctor, even if it's a Medicare-covered service. This means any payments from you to the provider will be out of pocket. Not only will Medicare not reimburse for the provider's services, but neither will any supplemental Medigap policies you may have.
Physicians who have never enrolled in Medicare but want to treat Medicare patients under private contracts must file an affidavit with the MAC or Carrier that serves their area. They will be provided with a UPIN (Unique Physician Identification Number) based on their tax identification number, which must be entered on the affidavit. The first time a physician opts out of Medicare, there is a 90-day grace period during which they can change their mind. To do so, they must notify the MACs or Carriers they filed an opt-out affidavit with and refund any money received from patients with private contracts that exceeded the Medicare-approved charges.
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EMTALA protections
EMTALA, or the Emergency Medical Treatment and Labor Act, is a federal law enacted by the United States Congress in 1986. It is part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). EMTALA provides protections for people in the U.S. requiring emergency medical care.
EMTALA was designed to prevent hospitals from refusing to treat patients or transferring them to other hospitals without first providing a medical screening examination (MSE) to ensure they are stable for transfer. This law applies to all patients, not just Medicare patients, and requires hospitals with emergency departments to screen and treat emergency medical conditions in a non-discriminatory manner, regardless of the patient's ability to pay, insurance status, national origin, race, creed, or color.
The law defines an emergency department as:
> "A specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions."
This means that outpatient clinics not equipped to handle medical emergencies are not covered by EMTALA and can refer patients to a nearby emergency department. EMTALA protections apply to the emergency department's physical space and the hospital's entire property, including the campus within 250 yards.
Hospitals have three main obligations under EMTALA:
- Anyone who comes and requests it must receive a medical screening examination to determine whether an emergency medical condition exists.
- Once an emergency medical condition is determined, the hospital must provide further treatment and examination until the condition is resolved or stabilized.
- The hospital cannot transfer or discharge patients needing emergency treatment without the patient's informed consent or stabilization, or when the patient's condition requires transfer to a better-equipped hospital.
EMTALA, as a federal law, supersedes state laws, including those that ban abortion. As such, doctors who perform emergency abortions to stabilize a patient are protected by EMTALA, and hospitals that fail to do so may face fines or be removed from Medicare.
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Finding Medicare-accepting hospitals
Most hospitals accept Medicare, specifically Original Medicare (Parts A and B). However, some hospitals may not, including Veterans Affairs and active military hospitals, as they operate with VA and military benefits. There are also a few other exceptions nationwide, including some public hospitals.
To find Medicare-accepting hospitals, you can use the online Medicare tool on Medicare.gov. This allows you to search for hospitals, doctors, nursing homes, hospice care, long-term facilities, and dialysis centres that accept Medicare. You can compare search results and see overall ratings, patient ratings, and more.
MedlinePlus also has directories that can help you find health professionals, services, and facilities that may accept Medicare or Medicaid payments.
It's important to note that even if a hospital accepts Medicare, there will still be out-of-pocket costs associated with your visit. If a hospital does not accept Medicare, you may have to pay the full amount upfront or set up a payment plan with the provider through a private contract.
Additionally, under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals receiving Medicare funds cannot refuse to treat people in emergency situations.
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Frequently asked questions
No, hospitals are not required to accept Medicare. However, the majority of hospitals accept Original Medicare (Parts A and B). Hospitals that do not accept Medicare include Veterans Affairs and active military hospitals.
Hospitals that participate in Medicare must meet certain requirements, including complying with federal, state, and local laws, having a governing body that is legally responsible for the hospital's conduct, and protecting patient rights. Additionally, Medicare is a major source of revenue for hospitals, providing health insurance coverage to a significant portion of the population.
If a hospital does not accept Medicare, patients may have to pay the full amount for their treatment upfront or set up a payment plan directly with the hospital. It is important to note that even if a hospital accepts Medicare, patients may still have out-of-pocket costs associated with their visit.
You can use the Medicare online tool to find hospitals in your area that accept Medicare. This tool allows you to search for hospitals, compare search results, and see overall ratings and patient ratings.
