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July 1, 2020
What Is Medicare Assignment?

What Is Medicare Assignment?

Some people have been with the same family doctor for years. Now that you’re on Medicare, you’ll need to find out if your long-time doctor accepts Medicare assignment.

When it comes to Medicare, providers agree to be participating providers, non-participating providers, or they opt-out altogether. Knowing and understanding where your doctors fall in these categories will help you make educated choices about your care.

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What Is Medicare Assignment?

When a doctor accepts Medicare assignment, it simply means they agree to take Medicare. Medicare has their own long list of approved charges, or what they will pay for every service under the sun. It’s usually far less than the “retail” cost of care, so when a doctor agrees to take Medicare, they agree to accept those rates.

You’ll see or hear the term “Medicare assignment” when you look up Medicare coverage for different procedures or doctor visits. It may also come up in conversations with your insurance agent about Medicare and supplemental coverage.

Only 4% of doctors don’t accept Medicare assignment.

As of 2020, approximately 96% of health care providers accept Medicare assignment. So in reality, you don’t need to be too concerned about your doctor not taking Medicare. However, even though most providers accept Medicare assignment, a quick call to make sure they accept it is always a good idea.

Rest assured that if a provider does not take Medicare, they are required to give you a form stating this, and you have to sign it saying you understand Medicare will not pay for the services. If you don’t sign that form, they cannot continue care.

If you’re looking for a new physician or for one that specializes in a medical area, you can use Medicare’s physician compare tool. It's easy to navigate by simply entering your location and a doctor's name or any condition or body part; then, it'll tell you who accepts Medicare assignment in your area. That’ll ensure you don’t waste any time, or possibly money, on a provider that doesn’t accept your Medicare insurance.

Related: How to Find a Good Doctor: 18 Steps to Help You Choose the Right Physician

Participating Providers

Participating providers agree to accept Medicare assignment and will only charge you the Medicare-approved amount for any covered services. The provider doesn’t charge you upfront but will bill Medicare for the cost of services.

After Medicare pays its portion, you could still owe a 20% copay.

This doesn’t mean you won’t owe any money, though. Medicare will pay 80% of the cost, and if you don’t have a Medicare Supplement, you may still be responsible for your 20% copay. 

For example, if you have Medicare and Medigap Plan F* or Plan G – and use a doctor or provider that accepts Medicare assignment – you won’t pay any coinsurance at all. With Plan F, you have zero out-of-pocket costs, and with Plan G, you only have to meet a very low deductible of $198 as of 2020.

*Plan F was phased out at the beginning of 2020 for new Medicare enrollees. However, if you’re already enrolled in Plan F, you can keep it.  If you were eligible for Medicare before January 1, 2020, you can still purchase it.

Related reading: 

Non-Participating Providers

Non-participating providers have not signed an agreement to accept the Medicare-approved amount for Medicare-covered services, but they can choose to do so. Since they haven’t agreed to the Medicare-approved amount, they can charge more for their services than participating providers. 

However, there is a limiting charge on how much doctors who don’t accept Medicare's approved amount can charge people on Medicare. Federal law sets the limit at no more than 15% of the Medicare-approved amount, but some states limit it even further. That 15% charge is called an excess charge.

Federal law doesn’t allow doctors that don’t accept Medicare assignment to charge more than 15% above the Medicare-approved amount unless they choose to opt-out completely. Some states limit this even further.

So, if you went to the doctor and the Medicare-approved rate for an office visit was $100, the excess charge could make your new total $115.

Depending on how your doctor handles payment, you may have to pay the total amount before leaving. If this is the case, Medicare will reimburse you 80% of the Medicare-approved charge, leaving you with the 20% copay plus the 15% upcharge. Using our same example, you would owe $20 for the copay and $15 for the excess charge making your total portion $35.

Here again, the Medicare Supplemental Plans F and G not only cover your coinsurance, but they also cover that 15% excess charge. You would still have zero out-of-pocket expenses except for Plan G’s $198 deductible in 2020.

Opt-Out Providers

Opt-Out Providers are those that prefer not to participate in the Medicare program at all. That 15% charge limit we just talked about doesn’t apply to these providers. They can charge whatever they want for services, and they won’t be sending any of the bills to Medicare.

Doctors who opt-out of Medicare assignment have no limit on how much they can charge for their medical services.

A doctor who opts-out of accepting Medicare requires a private contract between patient and provider, agreeing that neither will receive reimbursement from Medicare for services provided.

Popular Providers that Don’t Accept Medicare Assignment

Even though only 4% of healthcare providers don’t accept Medicare assignment, there are a few popular ones you may be interested to know.

Mayo Clinic is top-ranked for quality more often than any other health care organization. Their care is commonly referred to as world-class, but interestingly enough, they don’t accept Medicare assignment.

Another area of medical service that doesn’t accept Medicare assignment is Concierge Medicine. This type of practice, also known as direct primary care, is an alternative to the typical “fee-for-service” doctor’s office. Rather than pay a fee each time you visit your physician, concierge services require a membership fee.

What makes Concierge Medicine stand out from your typical doctor’s office is they are there to serve you – the practice is set up to serve the patient, not the physician.

David Winter, MD, a concierge medicine physician in Dallas explains to HealthLeaders Media that patients get valet parking, coffee and soft drinks when they arrive, 24/7 access to service, lengthier and unrushed appointments, and no idle time in the waiting room. In fact, they don’t call it a waiting room – they call it a greeting room.

Many have chosen to pay for this top-of-the-line service rather than utilize their Medicare benefits. To find a Concierge Medicine provider in your area, we recommend doing an online search for “concierge medicine in [city].” If there are any providers near you, they should come up right away.

Each person and medical need is different. There is nothing wrong with a provider that doesn’t accept Medicare assignment, and depending on your situation, the Mayo Clinic or Concierge Medicine might be the right choice for you.

The Lasso Healthcare Medicare MSA Is Unique

The Lasso Healthcare MSA is a $0 premium, high-deductible health insurance plan paired with a special deposit that you can use for qualified medical expenses. In 2020, Lasso Healthcare deposits $3,240 in a savings account, and you can use that money to pay for doctor visits, hospital stays, lab work, and the list goes on.

The Lasso Healthcare MSA does not have networks, which means you can see any doctor that accepts Medicare. However, you can also see doctors who don’t accept Medicare – it just works a little differently.

The Lasso Healthcare MSA is a $0 premium, high-deductible health insurance plan paired with a special deposit that you can use for qualified medical expenses.

So, let’s say the doctor is non-participating. They aren’t required to see you, but they can bill you up to that limiting charge, which is typically 15% more than the Medicare-approved rate. While this won’t count towards your plan deductible, you can use your deposit to pay for it!

The same goes for providers who opt-out of Medicare completely. This becomes a private contract between you and that provider. While this won’t count toward your plan deductible – and the plan won’t pay them if you’ve reached your deductible – you can use your annual deposit to pay for it.

As long as the item or service is a qualified medical expense (these are outlined in IRS Publication 502), you can use any funds left in your medical savings account.

The Lasso Healthcare MSA provides flexibility.

Benefits of Using Health Care Providers Who Accept Medicare Assignment

When you choose a doctor or physician who accepts Medicare assignment, you’re sure about several things:

  • You’ll know what charges to expect
  • You may pay less out-of-pocket 
  • Usually, you won’t have to pay anything until Medicare has been billed and pays their part
  • Your doctor will submit all the claims to Medicare for you

Downfalls of Using a Non-Participating Health Care Provider or One Who Opts-Out 

If you choose a doctor who either opts-out of Medicare or does not participate in Medicare assignment, you can expect to encounter the following:

  • You will typically pay out-of-pocket for all charges up-front, and then be reimbursed by Medicare
  • Your doctor may or may not file claims for you – you may have to do that yourself
  • You can be charged an excess charge of up to 15% on top of your copay which is 20%

Rest assured that if you have a Medicare Supplement Plan F or G, you don’t have to worry about excess charges.

In the case that you choose to see a health care provider that has opted-out of Medicare assignment, you’ll find:

  • Your provider doesn’t have to stick with the Medicare-approved amount or the limiting charge – they can charge you whatever they choose
  • You’ll pay the entire amount for all services – Medicare won’t reimburse you

This doesn’t mean that any of these categories of doctors is better than the other. They are simply going to cost you different amounts.

Conclusion

It's essential to understand what Medicare assignment means, as well as the different options available to you when it comes to your health care.

Medicare assignment gives you peace of mind knowing what to expect financially, but that doesn’t always mean it’s the right choice.

Carefully consider all aspects of your life and health before making a decision about which doctor to choose for your healthcare needs.

Before making any decisions, take a good look at your finances, know your medical needs, and talk with your insurance agent to make an educated decision on what is best for you.

You are ultimately responsible for your healthcare. Making well-informed decisions is a significant first step. 

Luke Hockaday
By
Luke Hockaday
Luke Hockaday is a Customer Success Rep here at Medicare Allies. Luke has been helping Medicare-eligible clients with their insurance and retirement-planning needs since 2011. Luke is passionate about 3 things, and 3 things only: senior insurance, football, and food!

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