There are so many things to consider when thinking about Medicare costs. Sure, things like deductibles, copays and coinsurance are important. But before these even come into play, you want to be sure you understand the financial relationship between your healthcare provider and Medicare. That way, there will be no surprises when you get the bill. And you can make sure you only pay what you can afford while still getting the healthcare you need.
First Things First – Accepting Assignment
When looking for a healthcare provider—like a doctor—it’s important to understand what “accepting assignment” means. “Assignment” is the agreement by a healthcare provider or supplier:
To be paid directly by Medicare,
To accept the payment amount Medicare approves for a service, and
To only make you pay your Medicare deductible and coinsurance.
When a healthcare provider “accepts assignment,” then, they agree to all these terms.
Know Your Providers: Participating, Non-Participating and Opting-Out
When starting on the path to finding a healthcare provider who accepts Medicare, it’s important to know the different types of providers you may find. There are three main types to consider:
May accept assignment of Medicare claims on a claim-by-claim basis.
Might charge you the full price for a service at the time you get it. They can charge you more than the Medicare-approved amount. In most cases they can only charge you up to 15% over the amount that non-participating providers are paid. There are some exceptions to this.
Providers Who Opt-Out
Have “opted-out” of the Medicare system
If they see people with Medicare, it will usually be on a case-by-case basis. They might also require you to sign a private contract, though they cannot force you to do so.
Accepting Patients vs. Accepting Assignment
Some providers do see patients with Medicare, but do not accept assignment. If this is the case, they can charge you up to 15% more than the amount Medicare approves. If you have Original Medicare Part A & Part B, this means you would pay your usual 20% coinsurance, plus an extra 15%. Here’s an example:
Medicare approved $100* for a doctor visit. But your doctor did not accept assignment. He charged you $115* for your visit. You would pay $35. This is 20% of the $100* amount Medicare approved + the extra $15 Medicare did not cover.
If you have a Medicare Advantage plan, your doctor agrees to accept the terms of the plan. This means they can only charge you the plan’s copayment. If your plan also charges a deductible, you would have to pay that, too.
What Are Excess Charges and What Can I Do about Them?
When looking for a doctor who accepts Medicare, you might also see the term “excess charges.” This is the difference between a doctor’s actual charge for services and the amount Medicare will pay. The most common example would happen if you went to a doctor who did not accept assignment and billed you more than Medicare’s approved amount. You have to pay these charges out of your own pocket.
If you’re worried about excess charges, you’ve got options. Call the Medicare helpline for tips on what your next steps should be. You can also look into other healthcare coverage or plans available in your area that might help you avoid or cover excess charges.
How can I find a Doctor Who Accepts Medicare?
It’s really not as hard as you might think.
In person – Call or stop by your doctor’s office—or any offices you might be interested in—and ask if they see Medicare patients. If they do, talk to them about what they do or don’t cover, accepting assignment, billing and other questions you might have.
Medicare.gov – The Physician Compare tool at Medicare.gov helps you find Medicare-enrolled doctors and healthcare providers in your area.
SHIP – You can also call your State Health Insurance Assistance Program (SHIP).
For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.
Medicare.gov: Physician Compare tool
Medicare.gov: Medicare and You (PDF)
MedicareMadeClear: Decision Roadmap
Y0066_120402_135711 File & Use 04092012