- A doctor who accepts assignment is agreeing to charge you no more than the amount Medicare pays for the service you receive. Medicare pays 80 percent of this amount, and you pay 20 percent (after you’ve met your annual Part B deductible). The doctor bills Medicare directly, as you are “assigning” Medicare to pay the doctor for your care.
- The preventive services that Medicare now provides for free (such as mammograms, colonoscopies, heart disease screenings and many others) are free of charge only if they’re provided by a doctor or other qualified health provider who accepts assignment.
- A doctor who does not accept assignment can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive.
- A doctor who has opted out of Medicare cannot bill Medicare for services you receive and is not bound by Medicare’s limitations on charges. You enter into a private contract with the doctor, agreeing to pay his or her bills directly. You cannot claim reimbursement from Medicare under this arrangement.
The chart shows an example of what Medicare pays and what you pay under each of these scenarios:
|Doctor accepts assignment||Doctor does not|
|Doctor has opted out of Medicare|
|Amount Medicare approves||$100||$100||NA|
|Medicare pays||$80 (80%)||$80 (80%)||$0|
|You pay||$20 (20%)||$20 (20%)||$120|
|Additional charge above Medicare-approved amount||$0||$15 (maximum|
15% in excess of amount Medicare approves)
|You pay in total||$20||$35||$120|
The same rules apply not just to doctors but also to most other outpatient providers. However, suppliers of durable medical equipment (such as wheelchairs and oxygen equipment) that don’t accept assignment are not bound by Medicare’s limits rule on charges and are allowed to bill you more than 15 percent above the Medicare-approved amount.
These rules affect you only if you’re in traditional Medicare. If you’re enrolled in a Medicare private health plan, you pay what your plan requires, as explained in the plan’s information packet and on its website.
To find doctors in your area who participate in Medicare (including those who accept assignment on all claims), go to Medicare's "Physician Compare" website. Or call the Medicare help line at 1-800-633-4227.
Patricia Barry is a senior editor for AARP Integrated Media and the author of “Medicare For Dummies” (Wiley/AARP, October 2013).
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En español | If you’re enrolled in the original Medicare program, it’s important to ask any doctor you see whether he or she accepts “assignment” — before you receive care — because this can have an impact on what you pay.
- A doctor who accepts assignment has agreed to accept the Medicare-approved amount as full payment for any covered service provided to a Medicare patient. The doctor sends the whole bill to Medicare. Medicare pays the 80 percent of the cost that it has decided is appropriate for the service, and you are responsible for the remaining 20 percent.
- A doctor who doesn’t accept assignment can charge up to 15 percent above the Medicare-approved amount for a service. You are responsible for the additional charge, on top of your regular 20 percent share of the cost. The doctor is supposed to submit your claim to Medicare, but you may have to pay the doctor at the time of service and then claim reimbursement from Medicare.
If you have Medigap insurance, all policies cover Part B’s 20 percent copays in full or in part. Two policies (F and G) cover excess charges from doctors who don’t accept assignment.
Note that these rules apply only to the original Medicare program. If you’re enrolled in a Medicare Advantage plan, such as an HMO or PPO, you pay the specific copays for doctors’ services that your plan requires.