What Is a Medicare-Approved Provider?

A Medicare-approved provider is a medical professional or institution certified by the Centers for Medicare & Medicaid Services (CMS) to provide services covered under the Medicare program. This includes doctors, hospitals, skilled nursing facilities, home health care agencies, and other providers of medically necessary supplies and services.

Providers must accept Medicare’s approved amount for patients enrolled in Original Medicare as full payment for covered services. This way, patients don’t have to worry about surprise bills or additional out-of-pocket costs.

Medicare also provides coverage for specific healthcare services through approved private companies under Medicare Advantage plans (Part C). These plans are an alternative to Original Medicare Part A and Part B and may include extra benefits like dental, vision, and prescription drug coverage. It’s important to note that the providers in a Medicare Advantage plan may differ from those in Original Medicare.

Why Is It Important?

Access to a Medicare-approved healthcare provider is vital for those relying on Medicare for their healthcare needs. Approved providers must meet certain standards set by the federal government and agree to accept payment from Medicare providers. This helps ensure Medicare patients receive quality Medicare coverage from trained professionals in an appropriate setting while protecting them from unexpected costs or bills.

What if My Provider Is Not Approved?

Selecting a healthcare provider outside Medicare’s approved network can increase costs. Let’s examine the three types of Medicare-associated providers and how they impact your costs and coverage.

Participating providers under Medicare – Medicare approves this provider type and accepts Medicare assignment, which is Medicare’s agreed fee structure for services. This group accounts for roughly 98% of providers nationally.

Non-participating providers under Medicare – This provider is open to accepting Medicare as an insurance provider, but they do not agree to Medicare’s fee structure. By opting to be a non-participating provider, they can charge up to 15% more than Medicare’s approved amount. This additional cost, the Part B Excess charge, is passed on to you unless you have a Medicare Supplement plan that covers this difference.

Opt-out providers under Medicare – This specific healthcare provider has chosen not to accept Medicare as a valid form of insurance. Consequently, when you seek care from an opt-out provider as a Medicare beneficiary, Medicare only provides coverage for emergency or urgently needed services, excluding other non-essential treatments.

You will bear the full responsibility for the cost of care. It is fortunate, however, that this group represents a minority, comprising approximately 1% of healthcare providers nationwide.

How to Find a Medicare-Approved Provider

Fortunately, finding a Medicare-approved provider in your area is easy. You can use Medicare’s “Physician Compare” tool to search for healthcare professionals by name, specialty, or location. This tool also allows you to compare providers based on patient reviews, quality scores, and more.

Additionally, you can contact Medicare directly to get a list of providers in your area. Be sure to check with each provider to ensure they accept your specific Medicare plan and to get information on their availability and fees.

Other Things to Consider

While it is crucial to choose a Medicare-approved provider, there are other important factors to consider when selecting healthcare. Proximity, availability, and personal preferences should also be taken into account. For instance, you may have a preference for a healthcare professional with expertise in a specific area.

Also, it is essential to consider any additional costs associated with your care, such as copays or deductibles. By considering these factors, you can make a well-informed decision that suits your needs and ensures quality healthcare.

Bottom Line

It is important to ensure your healthcare providers are Medicare-approved to get the best care and coverage possible. You can easily find a Medicare-approved provider using Medicare’s “Physician Compare” tool. Additionally, remember to account for other factors such as proximity, availability, and personal preferences when selecting a provider. Choosing the right provider will ensure Medicare beneficiaries get the best care possible.

Sources:  Medicare.govNational Council on AgingMedicare Interactive


  • What is it called when a doctor except the Medicare-approved amount?

    The term for when a doctor accepts the Medicare-approved amount is called assignment. Accepting assignment means that a doctor agrees to be reimbursed by Medicare and not charge you more than the approved amount for services covered under Medicare Part B. This helps protect you from unexpected medical bills, as your out-of-pocket costs are limited to your copayment or coinsurance

  • What does it mean to be accredited by CMS?

    Accreditation from the Centers for Medicare & Medicaid Services (CMS) means that a healthcare provider has been found to meet quality standards and is eligible to receive payment from CMS. This includes opting-in providers, who are able to bill Medicare directly for their services. Accreditation also implies that a provider participates in programs such as The Quality Improvement Evaluation System (QIES) and is using the latest healthcare technology. Accreditation may also be required by state and local governments to ensure the quality of care given by a provider. Ultimately, accreditation from CMS can help you feel secure in receiving coverage for your medical expenses.

Mark Prip

Since 2003, Mark Prip has been leading  Policy Guide, Inc., providing knowledgeable information about Medicare, life insurance, and dental coverage to clients in over forty states. With his unparalleled hands-on experience aiding countless Medicare beneficiaries in selecting an appropriate health plan, he is a prime example amongst other competitors for expertise and assistance. Mark has held his Florida Health & Life Insurance License (E051889) since 2003. View his license profile on the Florida Department of Insurance website.