Many doctors accept Medicare as a form of payment. This is called accepting assignment. Yet, a person may still have some out-of-pocket costs to consider.
A person should check that their doctor accepts Medicare before proceeding with any appointments or treatments. There are many ways to check whether a healthcare professional is participating.
This article looks at when doctors accept assignment, finding a doctor who accepts Medicare, and more.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Accepting assignment means that a doctor agrees to accept the Medicare-approved amount as full payment for covered health services and supplies. If a doctor accepts assignment, Medicare determines the amount that the doctor will be paid for health services and supplies.
The majority of doctors do accept assignment. If the doctor accepts assignment, the doctor:
- agrees to charge only the Medicare coinsurance and deductible
- will usually wait for Medicare to pay its share before billing an individual
- has to submit the claim directly to Medicare and cannot charge a person to file the claim
Out-of-pocket costs for an individual may be less if the doctor accepts assignment.
Learn about Medicare coverage for doctor visits.
A doctor who does not have an agreement with Medicare to accept assignment in every instance is referred to using the term “non-participating provider.”
If a healthcare professional does not have an agreement with Medicare, a person may be required to pay the entire bill at the time of service.
If the doctor is willing, they can submit a claim to Medicare directly for any Medicare-covered services they provide, but they cannot charge a person for submitting a claim.
Individuals may have to pay for a service out of pocket and then submit a claim themselves, using Form CMS-1490S for reimbursement.
Excess charges
Sometimes, a doctor can charge a person more than the Medicare-approved amount, creating an excess. The excess is any amount over the Medicare-approved cost.
In these cases, Medicare will not cover the excess. Some Medigap plans may help with these expenses.
Limiting charge
There is a limit to the amount a doctor can bill for a service, called a limiting charge. Non-participating professionals can charge up to 15% more than the Medicare-approved amount for a service that Medicare covers.
The limiting charge applies to doctors who have chosen to accept Medicare for some services only. The charge does not apply to professionals who are fully non-participating.
The term “opt-out provider” refers to a doctor who does not accept Medicare.
This means that a person will pay out of pocket for the cost of the treatment or service. The medical professional will set the cost of the bill.
To find a doctor who accepts Medicare, a person can visit the Medicare website and search for a doctor by location.
A person can also search by the last name of the healthcare professional or a keyword relating to a specialty or condition.
The search results will then provide a list of participating professionals in the location.
Private medical insurance companies administer Medicare Advantage plans, also known as Medicare Part C. These are bundled health plans that offer an alternative to Original Medicare (parts A and B).
Each Medicare Advantage plan has different rules for how a person may receive services, such as whether a person needs a referral to see a specialist and whether they need to see an in-network doctor.
What is a provider network?
The term “provider network” refers to a group of doctors, healthcare professionals, and hospitals with whom a plan has a contract. This makes them in network.
A healthcare professional who has no contract with a plan is an out-of-network professional. If a person chooses an out-of-network doctor, they may have additional costs, depending on their plan.
Seeing a specialist
Some Medicare Advantage (Part C) plans have different rules for referrals to a specialist.
- Health Maintenance Organization (HMO) plans: Usually, a person usually needs to obtain a referral from their primary care physician to see a specialist under an HMO plan.
- Preferred Provider Organization (PPO) plans: A person does not typically need a referral to see a specialist under a PPO plan. If a person uses an in-network specialist, their costs for covered services may be lower than if they use an out-of-network professional.
Learn about Medicare Advantage plans.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Most doctors accept Medicare. If a doctor accepts assignment, it means they have a formal agreement with Medicare to accept the Medicare-approved amount as full payment for all covered services.
Non-participating providers do not have a specific agreement with Medicare. This means that they do not need to accept Medicare, but some may, depending on the situation.
Opt-out providers do not accept Medicare.
A provider network is a group of healthcare professionals who have contracted with a particular health plan to provide cost-effective care to its members, making them in network.
To find a doctor who accepts Medicare, a person can visit the Medicare website and search using their location and either the name of the doctor or a keyword related to the doctor’s specialty.