Celebrating 60 Years of Service

Medicare Made Easy: Medicare Assignment under Original Medicare

The following information is provided by SHIP (Senior Health Insurance Program) Counselors of North Shore Senior Center. SHIP is a free state-wide health insurance counseling service for Medicare beneficiaries and their caregivers. SHIP is not affiliated with any insurance company and does not sell or solicit any type of insurance.

Under Original Medicare, doctors’ visits are covered under Part B. After you meet your deductible, Medicare typically pays 80% of the approved amount and you pay the remaining 20%. However, this is not always the case. How much you pay can vary from zero to 100% of the cost, depending on whether or not you are enrolled in a Medigap plan and whether or not your provider accepts Medicare assignment. Accepting Medicare assignment refers to how much or how little a doctor participates in the Medicare program, which then determines how a doctor’s fees are paid. The three types of participation in Original Medicare are described below. These categories do not apply to Medicare Advantage plans. Doctors serving beneficiaries enrolled in a Medicare Advantage plan are part of a managed-care network and reimbursement is structured differently.

Participating providers agree to accept the Medicare-approved amount as payment in full for their services. This is known as accepting assignment from Medicare. In this case, Medicare pays 80% of the Medicare-approved amount, and the beneficiary or supplemental insurer pays the remaining 20%.

Non-participating providers decide on a service-by-service basis whether or not to accept assignment from Medicare. A non-participating provider still files claims and is reimbursed by Medicare, but he or she must limit the total amount charged to 115% of the Medicare-approved amount. This extra 15% is called the limiting charge. Medicare pays 80% of the Medicare-approved amount, and the beneficiary or secondary insurance pays the remaining 20%, plus any excess fees up to 15%.

Private Contracting refers to doctors who have opted-out of the Medicare program completely. These doctors sign an affidavit stating that they will not submit any claims for any patients to Medicare. Patients pay 100% of the fees for doctors who opt-out. Doctors and patients must sign a contract outlining the terms of the arrangement to ensure patients understand that Medicare and supplemental insurers will not pay for any services provided by doctors who opt-out and contract privately with beneficiaries.

Concierge Care contracts are not the same as the first three private contracts described above but may be a component of any one of those three. Concierge Care provides enhanced services to patients who typically pay an annual membership fee or retainer to the concierge doctor. The retainer or membership fee and any fees for enhanced services are not covered by Medicare so beneficiaries pay the full cost. For services that are covered by Medicare, a concierge doctor is like any other and may be participating, non-participating or have opted-out.

While the vast majority of doctors accept Medicare, it’s best to discuss this before receiving care. This is particularly true when seeing a specialist or someone for the first time. You can also use the Physician Compare tool found at www.medicare.gov/physiciancompare/ to find doctors in your area who accept Medicare assignment.

If you have questions about this information or need assistance with any aspect of Medicare, please call our Senior and Family Services Department at 847.784.6040 to make an appointment with one of our SHIP Counselors.

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