What Is Medicare Assignment?
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.
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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.
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.
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How much will I have to pay if my provider doesn't accept Medicare assignment?
How do I submit a claim?
Can my provider charge to submit a claim?
Sources
- Lower Costs with Assignment. Medicare.gov.
- Fee Schedules. CMS.gov.
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