Medicare is a commonly used healthcare insurance option. Most people over the age of 65 qualify for Medicare benefits, as well as those with certain disabilities or end-stage renal disease. Because so many people utilize this insurance, they are contracted to work with healthcare providers all over the country to allow Medicare recipients to receive care at a range of different facilities. However, in order to limit out-of-pocket costs, it is important to make sure that you find providers that are in network, on assignment, or that adhere to the limiting charge policy.
What does it mean if your provider accepts assignment?
Accepting assignment means that your healthcare provider or facility is partnered with Medicare and is required by law to charge only the Medicare-approved amount for various services. This amount is preset by Medicare and is often less than many healthcare facilities would charge.
Because of this, when you receive care at a facility that accepts assignment, you will be required to pay lower out-of-pocket costs as Medicare will cover the full amount of the service cost. Your personal costs will only include your premium payment amount and any charges up to your deductible amount.
What if your provider does not accept assignment?
If your primary care physician or the facility where you are receiving care does not accept assignment, it means that they are a “non-participating” provider with Medicare. All physicians are required to file with Medicare, indicating that they either accept or do not accept assignment. If a provider does not accept assignment, it means that they are not required to charge only the Medicare-approved amount for services.
One possible option for non-participating providers is to choose to accept assignment for some services but to decline assignment for others. For services that they accept assignment for, they are only able to bill the Medicare-approved amount. However, for other services, they are allowed to charge up to 15 percent more than the Medicare-approved amount.
This limit cap is known as the limiting charge. Providers that do not fully participate only receive 95 percent of the Medicare-approved amount when Medicare reimburses them for the cost of care. In turn, the provider can charge the patient up to 15 percent more than this reimbursement amount. This extra charge will not be covered by Medicare, which causes Medicare recipients to incur greater out-of-pocket costs.
Other providers may decide not to accept Medicare assignment at all. These providers do not have to abide by any cost-limiting rules put in place by Medicare. Medicare will still reimburse 95 percent of the Medicare-approved amount, but these providers are able to charge any amount they choose for their services.
Choosing a provider based on your Medicare benefits
If you use Medicare as your primary health insurance, it is critical that you choose your provider and the facilities at which you seek care carefully. Many providers accept assignment from Medicare, and seeking care from these physicians will help to limit your out-of-pocket costs and ensure that you receive Medicare reimbursement. In addition, these providers will only charge you for your deductible amount and will file a claim with Medicare to cover the remainder of the care.
If you decide to seek care from a facility that does not fully accept assignment or does not accept assignment at all, you may be forced to pay more out of pocket. In addition to an extra 15 percent or more, you may also be forced to pay for all of your care out-of-pocket initially. The provider will help you file a claim with Medicare, but they may require full payment upfront.
Additionally, you should be aware that for providers not accepting full assignment, durable medical equipment and supplies are not subject to the limiting charge. This means that you may need to pay for all of these services out of pocket in addition to the rest of your care.
Related articles:
Choosing a Prescription Drug Plan During AEP(Opens in a new browser tab)
Retiring under the age of 65? Understanding Your Medicare Benefits(Opens in a new browser tab)