Does My Doctor Accept Medicare? Assignment, Excess Charges, and Opt-Out Providers

Here's the short answer. Most doctors accept Medicare, but there are three kinds of Medicare doctors, and your bill depends on which one you see. A doctor who accepts assignment takes the Medicare-approved amount as full payment, so you owe only your deductible and coinsurance. A non-participating doctor can accept assignment case by case, but can also charge you up to 15% above the approved amount, called the "limiting charge" or an excess charge. A doctor who has opted out of Medicare gets no Medicare payment at all; you sign a private contract and pay the full bill yourself, except in an emergency. Before your first visit, ask the office one question: "Do you accept Medicare assignment?" You can also check on Medicare.gov's Care Compare tool.

The three kinds of Medicare doctors

Source: Medicare.gov, "Does your provider accept Medicare as full payment?" and the "Medicare & You" handbook.

What "accepting assignment" gets you

Accepting assignment means the doctor, provider, or supplier agrees to take the Medicare-approved amount as payment in full for a covered service. If a provider accepts assignment, it applies to all of their Medicare-covered Part A and Part B services. Most doctors, providers, and suppliers accept assignment, but Medicare.gov says to always check that yours do. When they do:

• Your out-of-pocket costs may be lower.
• They agree to charge you only the Medicare deductible and coinsurance, and they usually wait for Medicare to pay its share before asking for yours.
• They must send the claim to Medicare themselves, and they can't charge you for doing it.

Under Original Medicare, you can use any provider in the U.S. who takes Medicare. For most Part B services you pay 20% of the approved amount after the yearly deductible, as long as your provider accepts assignment. Our Understanding Your Costs page has the current deductible.

Non-participating doctors and the 15% excess charge

Some doctors, providers, and suppliers don't sign a participation agreement but still accept the Medicare-approved amount on a case-by-case basis. Medicare calls them "non-participating." If your doctor doesn't accept assignment for your visit:

• You might have to pay the full amount at the time of service, and wait for Medicare to reimburse you.
• They still have to submit a claim to Medicare for covered services, and they can't charge you for submitting it. If they refuse, you can file your own claim using Medicare's claim form.
• They can charge more than the Medicare-approved amount. In many cases the charge can't be more than 15% above the approved amount for non-participating providers. This cap is called the "limiting charge."

The limiting charge doesn't apply to every Medicare-covered service. It doesn't apply to some supplies and durable medical equipment, so those costs could be higher. Your state may add its own rules on excess charges; your State Insurance Department can tell you.

Illustrative example only, not real prices. Suppose Medicare's approved amount for a visit is $100 and you've met your deductible. With a doctor who accepts assignment, you pay 20%, or $20. With a non-participating doctor who doesn't accept assignment and bills the full limiting charge, the bill can be up to $115, so you pay your $20 coinsurance plus the $15 excess charge, or $35.

Two ways to protect yourself from excess charges: some Medigap plans pay Part B excess charges, and if you have QMB status through Medicaid, providers can't bill you for Medicare cost-sharing at all. See Dual Eligible for the QMB protection.

Opt-out doctors and private contracts

Doctors and other providers who don't want to work with Medicare can "opt out." Medicare won't pay for items or services you get from an opt-out provider, except in emergencies. Providers opt out for a minimum of 2 years, and the opt-out renews automatically every 2 years unless the provider asks to end it. An opt-out provider can't pick and choose: they can't opt out for some Medicare patients and not others.

To see an opt-out provider, you sign a private contract and may need to pay upfront or set up a payment plan. Medicare won't pay for any service under that contract, even a service Medicare normally covers. The rules of a private contract:

• You and the provider set the payment terms, and you pay the full amount for the services you get.
• Your Medigap policy, if you have one, won't pay anything for those services.
• The provider must tell you if Medicare would pay for the service if you got it from a provider who accepts Medicare.
• The provider must tell you if they've been excluded from Medicare.
• The contract doesn't apply to emergency or urgent care.

Medicare.gov suggests contacting your State Health Insurance Assistance Program (SHIP) before you sign a private contract. Not every kind of provider can opt out. Doctors, dentists, podiatrists, optometrists, physician assistants, nurse practitioners, psychologists, clinical social workers, and several other types can. Chiropractors, physical therapists, occupational therapists, audiologists, and speech-language pathologists can't. An opt-out doctor can still order tests, equipment, and services for you that Medicare covers when you get them elsewhere.

How to check before your appointment

1. Ask the office directly. "Do you accept Medicare assignment?" is the exact phrase. "We take Medicare" can mean any of the three kinds. Medicare.gov's advice is to check with the provider ahead of time so you know whether you'll pay out of pocket.
2. Look the doctor up on Care Compare. Medicare.gov's Care Compare tool shows whether doctors and other providers accept assignment or participate in Medicare.
3. Check the opt-out list. Medicare publishes a lookup tool for providers who have opted out, at data.cms.gov.
4. Read your Medicare Summary Notice afterward. It shows the approved amount, what Medicare paid, and the most you can be billed. See How to read your Medicare Summary Notice.

Prescriptions from a doctor who doesn't accept Medicare

Your Part D plan covers a prescription if the prescriber accepts assignment or has an opt-out request on file with Medicare. If your prescriber has done neither, you can still get an initial 3-month fill. That gives the prescriber time to accept assignment or file an opt-out, and gives you time to find a new prescriber if you need to.

Common questions

Official sources

• Medicare.gov: Does your provider accept Medicare as full payment?
• Medicare.gov: Medicare costs
• Medicare.gov: Care Compare (find providers)
• CMS: Provider opt-out affidavits look-up tool
• CMS.gov: Opt out of Medicare (provider rules)
• Medicare.gov: "Medicare & You" handbook