Your Rights as a Medicare Patient When Your Doctor Is Part of an ACO
You may receive a notice or see a sign at your doctor's office saying the practice participates in an accountable care organization, or ACO. That can raise reasonable questions. Does it change your Medicare? Can you still see any doctor you want? Who sees your health information? This guide answers those questions in plain language for patients of practices that work with Advanced Health ACO in Venice and across Florida.
First, a quick refresher: what an ACO is
An accountable care organization is a group of doctors and other health care providers who agree to work together to coordinate care for people with Original Medicare, and to be measured on the quality and cost of that care. If you are new to the concept, start with our earlier article, What Is an Accountable Care Organization?
The key point for patients: an ACO is not an insurance plan, and it is not Medicare Advantage. You do not enroll in an ACO, and there is no ACO premium.
Your rights stay the same
If your doctor participates in an ACO, these things do not change:
- Your Original Medicare benefits. Your coverage, deductibles and coinsurance follow the normal Medicare rules. Medicare does not charge you more because your doctor is in an ACO.
- Your freedom to choose. You can still see any doctor, specialist or hospital that accepts Medicare, whether or not that provider is part of the ACO. No referral to an ACO provider is required just because your doctor participates.
- Your right to change doctors. You can switch primary care providers at any time.
- Your privacy protections. HIPAA and Medicare privacy rules continue to apply to everyone involved in your care.
Our Medicare beneficiaries page summarizes these protections.
What may change, usually for the better
ACOs exist to coordinate care, so you may notice:
- More reminders about preventive care, such as your annual wellness visit, recommended screenings and vaccines.
- Follow-up calls after a hospital stay or emergency visit, to review medications and make sure you have an appointment.
- Better communication between your primary care doctor and specialists such as your cardiologist, so tests are less likely to be repeated unnecessarily.
- Help managing chronic conditions such as high blood pressure, diabetes or heart failure, sometimes including care management programs.
Your health information and how to opt out of data sharing
To coordinate care, Medicare can share certain information from your Medicare claims with the ACO your doctor works with, such as dates of service, diagnoses and prescriptions filled. This helps the care team see the full picture, including care you received elsewhere.
You have a choice. If you do not want Medicare to share your claims information with an ACO, you can call 1-800-MEDICARE (1-800-633-4227); TTY users can call 1-877-486-2048. Declining data sharing does not affect your Medicare benefits or your ability to see your doctor. Some limited information may still be used for certain program purposes, such as quality measurement; Medicare can explain the details when you call.
How patients are connected to an ACO
In Medicare's accountable care programs, patients are generally connected, or "aligned," to an ACO based on where they receive most of their primary care, as shown in Medicare claims. In many programs you can also confirm your primary clinician yourself by signing in to your account at Medicare.gov. You never have to do anything to keep your Medicare benefits, and specific alignment rules vary by CMS program.
About Advanced Health ACO's status
We believe patients deserve transparency. Advanced Health ACO publishes its participant list, CMS model information and, once available, its quality and financial results on our ACO public reporting page. As that page explains, our first performance year is planned under a CMS Innovation Center model and is subject to a final participation agreement with CMS. We update the page as the program progresses.
How to make the most of coordinated care
- Bring an up-to-date medication list, including over-the-counter drugs and supplements, to every visit.
- Tell your primary care doctor about visits to specialists, urgent care or the hospital.
- Schedule your annual wellness visit and ask which screenings are due.
- Answer follow-up calls from your doctor's care team after a hospital stay; they are there to help you recover safely.
Watch out for scams
Because ACOs are unfamiliar to many people, scammers sometimes use the term. Keep these rules in mind:
- You never need to "sign up" or pay to join an ACO.
- Your doctor's ACO will not call you asking for your Medicare number, Social Security number or bank information.
- No one can require you to switch doctors or give up Original Medicare because of an ACO.
If something feels wrong, hang up and call 1-800-MEDICARE or your doctor's office directly using a number you already know.
Questions patients often ask
Will my out-of-pocket costs go up?
No. Medicare pays your providers under the usual Original Medicare rules, and your costs are not increased because your doctor participates in an ACO.
I have a Medicare Advantage plan. Does this apply to me?
Medicare's ACO programs are built around Original Medicare. If you have a Medicare Advantage plan, your plan's own rules and network apply; contact your plan with questions.
Who can I call with questions?
For Medicare questions, call 1-800-MEDICARE. For questions about our ACO, visit our FAQ or contact us at 941-412-0026. Advanced Health ACO works with practices in the Advanced Health Associates network; you can find office details on our locations page.
This article is general educational information, not medical, legal or insurance advice. Medicare program rules can change; for the most current information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).