Summary: If a provider accepts Medicare assignment, they accept the Medicare-approved amount for a covered service. Though most providers accept assignment, not all do. In this article, we’ll explain the differences between participating, non-participating, and opt-out providers. You’ll also learn how to find physicians in your area who accept Medicare assignment. Estimated Read Time: 5 min
What is Medicare Assignment
Medicare assignment is an agreement by your doctor or other healthcare providers to accept the Medicare-approved amount as the full cost for a covered service. Providers who “accept assignment” bill Medicare directly for Part B-covered services and cannot charge you more than the applicable deductible and coinsurance.
Most healthcare providers who opt-in to Medicare accept assignment. In fact, CMS reported in its Medicare Participation for Calendar Year 2024 announcement that 98 percent of Medicare providers accepted assignment in 2023.
Providers who accept Medicare are divided into two groups: Participating providers and non-participating providers. Providers can decide annually whether they want to participate in Medicare assignment, or if they want to be non-participating.
Providers who do not accept Medicare Assignment can charge up to 15% above the Medicare-approved cost for a service. If this is the case, you will be responsible for the entire amount (up to 15%) above what Medicare covers.
Below, we’ll take a closer look at participating, non-participating, and opt-out physicians.
Medicare Participating Providers: Providers Who Accept Medicare Assignment
Healthcare providers who accept Medicare assignment are known as “participating providers”. To participate in Medicare assignment, a provider must enter an agreement with Medicare called the Participating Physician or Supplier Agreement. When a provider signs this agreement, they agree to accept the Medicare-approved charge as the full charge of the service. They cannot charge the beneficiary more than the applicable deductible and coinsurance for covered services.
Each year, providers can decide whether they want to be a participating or non-participating provider. Participating in Medicare assignment is not only beneficial to patients, but to providers as well. Participating providers get paid by Medicare directly, and when a participating provider bills Medicare, Medicare will automatically forward the claim information to Medicare Supplement insurers. This makes the billing process much easier on the provider’s end.
Medicare Non-Participating Providers: Providers Who Don’t Accept Assignment
Healthcare providers who are “non-participating” providers do not agree to accept assignment and can charge up to 15% over the Medicare-approved amount for a service. Non-participating Medicare providers still accept Medicare patients. However they have not agreed to accept the Medicare-approved cost as the full cost for their service.
Doctors who do not sign an assignment agreement with Medicare can still choose to accept assignment on a case-by-case basis. When non-participating providers do add on excess charges, they cannot charge more than 15% over the Medicare-approved amount. It’s worth noting that providers do not have to charge the maximum 15%; they may only charge 5% or 10% over the Medicare-approved amount.
When you receive a Medicare-covered service at a non-participating provider, you may need to pay the full amount at the time of your service; a claim will need to be submitted to Medicare for you to be reimbursed. Prior to receiving care, your provider should give you an Advanced Beneficiary Notice (ABN) to read and sign. This notice will detail the services you are receiving and their costs.
Non-participating providers should include a CMS-approved unassigned claim statement in the additional information section of your Advanced Beneficiary Notice. This statement will read:
“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
This statement basically summarizes how excess charges work: Medicare will pay the Medicare-approved amount, but you may end up paying more than that.
Your provider should submit a claim to Medicare for any covered services, however, if they refuse to submit a claim, you can do so yourself by using CMS form 1490S.
Opt-Out Providers: What You Need to Know
Opt-out providers are different than non-participating providers because they completely opt out of Medicare. What does this mean for you? If you receive supplies or services from a provider who opted out of Medicare, Medicare will not pay for any of it (except for emergencies).
Physicians who opt-out of Medicare are even harder to find than non-participating providers. According to a report by KFF.org, only 1.1% of physicians opted out of Medicare in 2023. Of those who opted out, most are physicians in specialty fields such as psychiatry, plastic and reconstructive surgery, and neurology.
How to Find A Doctor Who Accepts Medicare Assignment
Finding a doctor who accepts Medicare patients and accepts Medicare assignment is generally easier than finding a provider who doesn’t accept assignment. As we mentioned above, of all the providers who accept Medicare patients, 98 percent accept assignment.
The easiest way to find a doctor or healthcare provider who accepts Medicare assignment is by visiting Medicare.gov and using their Compare Care Near You tool. When you search for providers in your area, the Care Compare tool will let you know whether a provider is a participating or non-participating provider.
If a provider is part of a group practice that involves multiple providers, then all providers in that group must have the same participation status. As an example, we have three doctors, Dr. Smith, Dr. Jones, and Dr. Shoemaker, who are all part of a group practice called “Health Care LLC”. The group decides to accept Medicare assignment and become a participating provider. Dr. Smith decides he does not want to accept assignment, however, because he is part of the “Health Care LLC” group, he must remain a participating provider.
Using Medicare’s Care Compare tool, you can select a group practice and see their participation status. You can then view all providers who are part of that group. This makes finding doctors who accept assignment even easier.
To ensure you don’t end up paying more out-of-pocket costs than you anticipated, it’s always a good idea to check with your provider if they are a participating Medicare provider. If you have questions regarding Medicare assignment or are having trouble determining whether a provider is a participating provider, you can contact Medicare directly at 1-800-633-4227. If you have questions about excess charges or other Medicare costs and would like to speak with a licensed insurance agent, you can contact us at the number above.
Sources
Announcement About Medicare Participation for Calendar Year 2024, Centers for Medicare & Medicaid Services. Accessed January 2024
https://www.cms.gov/files/document/medicare-participation-announcement.pdf
Annual Medicare Participation Announcement, CMS.gov. Accessed January 2024
https://www.cms.gov/medicare-participation
Does Your Provider Accept Medicare as Full Payment? Medicare.gov. Accessed January 2024
https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare
