Most doctors accept Medicare as full payment for their services. Some accept it only for certain services, and others do not accept it at all.
What does this mean for you?
If you have Original Medicare, it means you should try to use doctors, hospitals, medical equipment suppliers and other healthcare providers that participate or “accept assignment” in Medicare. Such providers have signed agreements to take Medicare as payment in full for their services.
If your doctor or other provider accepts assignment:
Your out-of-pocket costs may be less.
The provider has to submit your claim directly to Medicare and cannot charge you for submitting the claim.
Some doctors and other providers have not signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for some services. These providers are called “non-participating” providers.
If your doctor or other provider does not accept assignment:
• You may have to pay the entire bill at the time of service. Your provider is then supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
• The provider cannot charge you for submitting a claim. If they don’t submit the Medicare claim once you ask them to, call 1-800-MEDICARE.
In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S in order to get paid back.
The provider can charge you more than the Medicare-approved amount, but there is a limit. Non-participating providers are paid 95 percent of the Medicare-approved amount. They can only charge you up to 15 percent over the amount that non-participating providers are paid.
The 15 percent limit applies only to certain Medicare-covered services and does not apply to some medical supplies and durable medical equipment.
Some doctors and other providers don’t want to enroll in the Medicare program at all. You can still visit these “opt out” providers, but they must enter into a private contract with you (unless you are in need of emergency or urgently needed care).
A private contract is a written agreement between you and a doctor or other provider who has decided not to provide services to anyone through Medicare. The private contract only applies to services you get from the provider who asked you to sign it.
If you sign a private contract with an opt-out doctor or other provider, keep in mind that Medicare will not pay any amount for the services you get from that provider, even Medicare-covered services.
• You will have to pay the full amount this provider charges you. You and your provider will set up your own payment terms through the contract.
If you have a Medicare Supplement Insurance (Medigap) policy, it will not pay anything for the services you get. Call your insurance company before you get the service if you have questions.
Your provider must tell you if Medicare would pay for the service if you got it from another provider who accepts Medicare.
Your provider must tell you if he or she has been excluded from Medicare.
You cannot be asked to sign a private contract for emergency or urgent care.
You are always free to get services not covered by Medicare if you choose to pay for them yourself.
You do not have to sign a private contract. You can always go to another provider who participates (accepts assignment) in Medicare.
Be sure to ask your physician or other provider if they are participating, non-participating or opt-out. You can also check by calling 1-800-MEDICARE or by using Medicare’s Physician Compare tool on www.medicare.gov.
You may want to contact your State Health Insurance Assistance Program (SHIP) to get free help before signing a private contract with any doctor or other health care provider.
Greg Dill is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).