what is medicare assignment for doctor

How well do you know Social Security? Take the quiz to test your knowledge.

AARP daily Crossword Puzzle

Hotels with AARP discounts

Life Insurance

AARP Dental Insurance Plans

AARP MEMBERSHIP 

AARP Membership — $12 for your first year when you sign up for Automatic Renewal

Get instant access to members-only products, hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. 

• right_container

Work & Jobs

Social Security

• AARP en Español

• Membership & Benefits
• Members Edition

AARP Rewards

• AARP Rewards %{points}%

Conditions & Treatments

Drugs & Supplements

Health Care & Coverage

Health Benefits

AARP Hearing Center

Advice on Tinnitus and Hearing Loss

Get Happier

Creating Social Connections

Brain Health Resources

Tools and Explainers on Brain Health

Your Health

8 Major Health Risks for People 50+

Scams & Fraud

Personal Finance

Money Benefits

View and Report Scams in Your Area

AARP Foundation Tax-Aide

Free Tax Preparation Assistance

AARP Money Map

Get Your Finances Back on Track

How to Protect What You Collect

Small Business

Age Discrimination

Flexible Work

Freelance Jobs You Can Do From Home

AARP Skills Builder

Online Courses to Boost Your Career

31 Great Ways to Boost Your Career

ON-DEMAND WEBINARS

Tips to Enhance Your Job Search

Get More out of Your Benefits

When to Start Taking Social Security

10 Top Social Security FAQs

Social Security Benefits Calculator

Medicare Made Easy

Original vs. Medicare Advantage

Enrollment Guide

Step-by-Step Tool for First-Timers

Prescription Drugs

9 Biggest Changes Under New Rx Law

Medicare FAQs

Quick Answers to Your Top Questions

Care at Home

Financial & Legal

Life Balance

LONG-TERM CARE

​Understanding Basics of LTC Insurance​

State Guides

Assistance and Services in Your Area

Prepare to Care Guides

How to Develop a Caregiving Plan

End of Life

How to Cope With Grief, Loss

Recently Played

Word & Trivia

Atari® & Retro

Members Only

Staying Sharp

Mobile Apps

More About Games

Right Again! Trivia

Right Again! Trivia – Sports

Atari® Video Games

Throwback Thursday Crossword

Travel Tips

Vacation Ideas

Destinations

Travel Benefits

Beach Vacation Ideas

Fun Beach Vacations

Road Trips For Every Personality

Passport Access

Passports Can Be Renewed Online

AARP National Park Guide

Black Canyon of the Gunnison

Entertainment & Style

Family & Relationships

Personal Tech

Home & Living

Celebrities

Beauty & Style

Movies for Grownups

Summer Movie Preview

Jon Bon Jovi’s Long Journey Back

Looking Back

50 World Changers Turning 50

Sex & Dating

7 Dating Dos and 7 Don'ts

Friends & Family

Veterinarians May Use AI to Treat Pets

Home Technology

Caregiver’s Guide to Smart Home Tech

Virtual Community Center

Join Free Tech Help Events

Creative Ways to Store Your Pets Gear

Meals to Make in the Microwave

Wearing Shoes Inside: Pros vs. Cons

Driver Safety

Maintenance & Safety

Trends & Technology

AARP Smart Guide

How to Clean Your Car

We Need To Talk

Assess Your Loved One's Driving Skills

AARP Smart Driver Course

Building Resilience in Difficult Times

Tips for Finding Your Calm

Weight Loss After 50 Challenge

Cautionary Tales of Today's Biggest Scams

7 Top Podcasts for Armchair Travelers

Jean Chatzky: ‘Closing the Savings Gap’

Quick Digest of Today's Top News

AARP Top Tips for Navigating Life

Get Moving With Our Workout Series

You are now leaving AARP.org and going to a website that is not operated by AARP. A different privacy policy and terms of service will apply.

What is Medicare assignment and how does it work?

Kimberly Lankford,

​Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they’re accepting assignment.

A doctor who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. By comparison, a doctor who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.

That’s why it’s important to ask if a provider accepts assignment before you receive care, even if they accept Medicare patients. If a doctor doesn’t accept assignment, you will pay more for that physician’s services compared with one who does.

Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. 

How much do I pay if my doctor accepts assignment?

If your doctor accepts assignment, you will usually pay 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible. Because Medicare Part B covers doctor and outpatient services, your $240 deductible for Part B in 2024 applies before most coverage begins.

All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and will bill you the remaining 20 percent. You can get some preventive services and screenings, such as mammograms and colonoscopies , without paying a deductible or coinsurance if the provider accepts assignment. 

What if my doctor doesn’t accept assignment?

A doctor who takes Medicare but doesn’t accept assignment can still treat Medicare patients but won’t always accept the Medicare-approved amount as payment in full.

This means they can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive, called “balance billing.” In this case, you’re responsible for the additional charge, plus the regular 20 percent coinsurance, as your share of the cost.

How to cover the extra cost? If you have a Medicare supplement policy , better known as Medigap, it may cover the extra 15 percent, called Medicare Part B excess charges.

All Medigap policies cover Part B’s 20 percent coinsurance in full or in part. The F and G policies cover the 15 percent excess charges from doctors who don’t accept assignment, but Plan F is no longer available to new enrollees, only those eligible for Medicare before Jan. 1, 2020, even if they haven’t enrolled in Medicare yet. However, anyone who is enrolled in original Medicare can apply for Plan G.

Remember that Medigap policies only cover excess charges for doctors who accept Medicare but don’t accept assignment, and they won’t cover costs for doctors who opt out of Medicare entirely.

Good to know. A few states limit the amount of excess fees a doctor can charge Medicare patients. For example, Massachusetts and Ohio prohibit balance billing, requiring doctors who accept Medicare to take the Medicare-approved amount. New York limits excess charges to 5 percent over the Medicare-approved amount for most services, rather than 15 percent.

AARP NEWSLETTERS

%{ newsLetterPromoText  }%

%{ description }%

Privacy Policy

ARTICLE CONTINUES AFTER ADVERTISEMENT

How do I find doctors who accept assignment?

Before you start working with a new doctor, ask whether he or she accepts assignment. About 98 percent of providers billing Medicare are participating providers, which means they accept assignment on all Medicare claims, according to KFF.

You can get help finding doctors and other providers in your area who accept assignment by zip code using Medicare’s Physician Compare tool .

Those who accept assignment have this note under the name: “Charges the Medicare-approved amount (so you pay less out of pocket).” However, not all doctors who accept assignment are accepting new Medicare patients.

AARP® Vision Plans from VSP™

Vision insurance plans designed for members and their families

What does it mean if a doctor opts out of Medicare?

Doctors who opt out of Medicare can’t bill Medicare for services you receive. They also aren’t bound by Medicare’s limitations on charges.

In this case, you enter into a private contract with the provider and agree to pay the full bill. Be aware that neither Medicare nor your Medigap plan will reimburse you for these charges.

In 2023, only 1 percent of physicians who aren’t pediatricians opted out of the Medicare program, according to KFF. The percentage is larger for some specialties — 7.7 percent of psychiatrists and 4.2 percent of plastic and reconstructive surgeons have opted out of Medicare.

Keep in mind

These rules apply to original Medicare. Other factors determine costs if you choose to get coverage through a private Medicare Advantage plan . Most Medicare Advantage plans have provider networks, and they may charge more or not cover services from out-of-network providers.

Before choosing a Medicare Advantage plan, find out whether your chosen doctor or provider is covered and identify how much you’ll pay. You can use the Medicare Plan Finder to compare the Medicare Advantage plans and their out-of-pocket costs in your area.

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

Unlock Access to AARP Members Edition

Already a Member? Login

More on Medicare

How Do I Create a Personal Online Medicare Account?

You can do a lot when you decide to look electronically

I Got a Medicare Summary Notice in the Mail. What Is It?

This statement shows what was billed, paid in past 3 months

Understanding Medicare’s Options: Parts A, B, C and D

Making sense of the alphabet soup of health care choices

Recommended for You

AARP Value & Member Benefits

Learn, earn and redeem points for rewards with our free loyalty program

AARP® Dental Insurance Plan administered by Delta Dental Insurance Company

Dental insurance plans for members and their families

The National Hearing Test

Members can take a free hearing test by phone

AARP® Staying Sharp®

Activities, recipes, challenges and more with full access to AARP Staying Sharp®

SAVE MONEY WITH THESE LIMITED-TIME OFFERS

What You Need to Know About Medicare Assignment

If you are one of the more than 63 million Americans enrolled in Medicare and are on the lookout for a new provider, you may wonder what your options are. A good place to start? Weighing the pros and cons of choosing an Original Medicare plan versus a Medicare Advantage plan—both of which have their upsides.

Let’s say you decide on an Original Medicare plan, which many U.S. doctors accept. In your research, however, you come across the term “Medicare assignment.” Cue the head-scratching. What exactly does that mean, and how might it affect your coverage costs?

What is Medicare Assignment?

It turns out that Medicare assignment   is a concept you need to understand before seeing a new doctor. First things first: Ask your doctor if they “accept assignment”—that exact phrasing—which means they have agreed to accept a Medicare-approved amount as full payment for any Medicare-covered service provided to you. If your doctor accepts assignment, that means they’ll send your whole medical bill to Medicare, and then Medicare pays 80% of the cost, while you are responsible for the remaining 20%.

A doctor who doesn’t accept assignment, however, could charge up to 15% more than the Medicare-approved amount for their services, depending on what state you live in, shouldering you with not only that additional cost but also your 20% share of the original cost. Additionally, the doctor is supposed to submit your claim to Medicare, but you may have to pay them on the day of service and then file a reimbursement claim from Medicare after the fact.

Worried that your doctor will not accept assignment? Luckily, 98% of U.S. physicians who accept Medicare patients also accept Medicare assignment, according to the U.S. Centers for Medicare & Medicaid Services (CMS). They are known as assignment providers, participating providers, or Medicare-enrolled providers.

It can be confusing. Here’s how to assess whether your provider accepts Medicare assignment, and what that means for your out-of-pocket costs:

The 3 Types of Original Medicare Providers

1. participating providers, or those who accept medicare assignment.

These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don’t have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit. Typically, Medicare pays 80% of the cost, while you are responsible for the remaining 20%, as long as you have met your deductible.

2. Non-participating providers

“Most providers accept Medicare, but a small percentage of doctors are known as non-participating providers,” explains Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation (NPAF) in Washington D.C. “These may be more expensive,” she adds. Also known as non-par providers, these physicians may accept Medicare patients and insurance, but they have not agreed to take assignment Medicare in all cases. That means they’re not held to the Medicare-approved amount as payment in full. As a reminder, a doctor who doesn’t accept assignment can charge up to 15% more than the Medicare-approved amount, depending on what part of the country you live in, and you will have to pay that additional amount plus your 20% share of the original cost.

What does that mean for you? Besides being charged more than the Medicare-approved amount, you might also be required to do some legwork to get reimbursed by Medicare.

• You may have to pay the entire bill at the time of service and wait to be reimbursed 80% of the Medicare-approved amount. In most cases, the provider will submit the claim for you. But sometimes, you’ll have to submit it yourself.
• Depending on the state you live in, the provider may also charge you as much as 15% more than the Medicare-approved amount. (In New York state, for example, that add-on charge is limited to 5%.) This is called a limiting charge—and the difference, called the balance bill, is your responsibility.

There are some non-par providers, however, who accept Medicare assignment   for certain services, on a case-by-case basis. Those may include any of the services—anything from hospital and hospice care to lab tests and surgery—available from any assignment-accepting doctor, with a key exception: If a non-par provider accepts assignment for a particular service, they cannot bill you more than the regular Medicare deductible and coinsurance amount for that specific treatment. Just as it’s important to confirm whether your doctor accepts assignment, it’s also important to confirm which services are included at assignment.

3. Opt-out providers

A small percentage of providers do not participate in Medicare at all. In 2020, for example, only 1% of all non-pediatric physicians nationwide opted out, and of that group, 42% were psychiatrists. “Some doctors opt out of providing Medicare coverage altogether,” notes Donovan.“In that case, the patient would pay privately.” If you were interested in seeing a physician who had opted out of Medicare, you would have to enter a private contract with that provider, and neither you nor the provider would be eligible for reimbursement from Medicare.

How do I know if my doctor accepts Medicare assignment?

The best way to find out whether your provider accepts Medicare assignment is simply to ask. First, confirm whether they are participating or non-participating—and if they are non-participating, ask whether they accept Medicare assignment for certain services.

Also, make sure to ask your provider exactly how they will be billing Medicare and what charges you might expect at the time of your visit so that you’re on the same page from the start.

Is seeing a non-participating provider who accepts Medicare assignment more expensive?

The short answer is yes. There are usually out-of-pocket costs after you’re reimbursed. But it may not cost as much as you think, and it may not be much more than if you see a participating provider. Still, it could be challenging if you’re on a fixed income.

For example, let’s say you’re seeing a physical therapist who accepts Medicare patients but not Medicare assignment. Medicare will pay $95 per visit to the provider; but your provider bills the service at $115. In most states, you’re responsible for a 15% limiting charge above $95. In this case, your bill would be 115% of $95, or $109.25.

Once you get your $95 reimbursement back from Medicare, your cost for the visit—the balance bill—would be $14.25 (plus any deductibles or copays) .

In some states, the maximum cap on the limiting charge is less than 15%. As mentioned earlier, New York state, for instance, allows only a 5% surcharge, which means that physical therapy appointment would cost you just $4.75 extra.

Bottom line: Medicare assignment providers and non-participating providers who agree to accept Medicare assignment are both viable options for patients. So if you want to see a particular provider, don’t rule them out just because they’re non-par.

While seeing a non-participating provider may still be affordable, ultimately, the biggest headache may be keeping track of claims and reimbursements, or simply setting aside the right amount of money to pay for your visit up front.

Before you schedule a visit, be sure to ask how much the service will cost. You can also estimate the payment amount based on Medicare-approved charges. A good place to start is this  out-of-pocket expense calculator  provided by the CMS.

What if I see a provider who opts out of Medicare altogether?

An opt-out provider will create a private contract with you, underscoring the terms of your agreement. But Medicare will not reimburse either of you for services.

Seeing a provider who does not accept Medicare will likely be more expensive. And your visits won’t count toward your deductible. But you may be able to work out paying reduced fees on a sliding scale for that provider’s services, all of which would be laid out in your contract.

What You Need to Know About Medicare Assignment

If you are one of the more than 63 million Americans enrolled in Medicare and are on the lookout for a new provider, you may wonder what your options are. A good place to start? Weighing the pros and cons of choosing an Original Medicare plan versus a Medicare Advantage plan—both of which have their upsides.

Let’s say you decide on an Original Medicare plan, which many U.S. doctors accept. In your research, however, you come across the term “Medicare assignment.” Cue the head-scratching. What exactly does that mean, and how might it affect your coverage costs?

What is Medicare Assignment?

It turns out that Medicare assignment   is a concept you need to understand before seeing a new doctor. First things first: Ask your doctor if they “accept assignment”—that exact phrasing—which means they have agreed to accept a Medicare-approved amount as full payment for any Medicare-covered service provided to you. If your doctor accepts assignment, that means they’ll send your whole medical bill to Medicare, and then Medicare pays 80% of the cost, while you are responsible for the remaining 20%.

A doctor who doesn’t accept assignment, however, could charge up to 15% more than the Medicare-approved amount for their services, depending on what state you live in, shouldering you with not only that additional cost but also your 20% share of the original cost. Additionally, the doctor is supposed to submit your claim to Medicare, but you may have to pay them on the day of service and then file a reimbursement claim from Medicare after the fact.

Worried that your doctor will not accept assignment? Luckily, 98% of U.S. physicians who accept Medicare patients also accept Medicare assignment, according to the U.S. Centers for Medicare & Medicaid Services (CMS). They are known as assignment providers, participating providers, or Medicare-enrolled providers.

It can be confusing. Here’s how to assess whether your provider accepts Medicare assignment, and what that means for your out-of-pocket costs:

The 3 Types of Original Medicare Providers

1. participating providers, or those who accept medicare assignment.

These providers have an agreement with Medicare to accept the Medicare-approved amount as full payment for their services. You don’t have to pay anything other than a copay or coinsurance (depending on your plan) at the time of your visit. Typically, Medicare pays 80% of the cost, while you are responsible for the remaining 20%, as long as you have met your deductible.

2. Non-participating providers

“Most providers accept Medicare, but a small percentage of doctors are known as non-participating providers,” explains Caitlin Donovan, senior director of public relations at the National Patient Advocate Foundation (NPAF) in Washington D.C. “These may be more expensive,” she adds. Also known as non-par providers, these physicians may accept Medicare patients and insurance, but they have not agreed to take assignment Medicare in all cases. That means they’re not held to the Medicare-approved amount as payment in full. As a reminder, a doctor who doesn’t accept assignment can charge up to 15% more than the Medicare-approved amount, depending on what part of the country you live in, and you will have to pay that additional amount plus your 20% share of the original cost.

What does that mean for you? Besides being charged more than the Medicare-approved amount, you might also be required to do some legwork to get reimbursed by Medicare.

• You may have to pay the entire bill at the time of service and wait to be reimbursed 80% of the Medicare-approved amount. In most cases, the provider will submit the claim for you. But sometimes, you’ll have to submit it yourself.
• Depending on the state you live in, the provider may also charge you as much as 15% more than the Medicare-approved amount. (In New York state, for example, that add-on charge is limited to 5%.) This is called a limiting charge—and the difference, called the balance bill, is your responsibility.

There are some non-par providers, however, who accept Medicare assignment   for certain services, on a case-by-case basis. Those may include any of the services—anything from hospital and hospice care to lab tests and surgery—available from any assignment-accepting doctor, with a key exception: If a non-par provider accepts assignment for a particular service, they cannot bill you more than the regular Medicare deductible and coinsurance amount for that specific treatment. Just as it’s important to confirm whether your doctor accepts assignment, it’s also important to confirm which services are included at assignment.

3. Opt-out providers

A small percentage of providers do not participate in Medicare at all. In 2020, for example, only 1% of all non-pediatric physicians nationwide opted out, and of that group, 42% were psychiatrists. “Some doctors opt out of providing Medicare coverage altogether,” notes Donovan.“In that case, the patient would pay privately.” If you were interested in seeing a physician who had opted out of Medicare, you would have to enter a private contract with that provider, and neither you nor the provider would be eligible for reimbursement from Medicare.

How do I know if my doctor accepts Medicare assignment?

The best way to find out whether your provider accepts Medicare assignment is simply to ask. First, confirm whether they are participating or non-participating—and if they are non-participating, ask whether they accept Medicare assignment for certain services.

Also, make sure to ask your provider exactly how they will be billing Medicare and what charges you might expect at the time of your visit so that you’re on the same page from the start.

Is seeing a non-participating provider who accepts Medicare assignment more expensive?

The short answer is yes. There are usually out-of-pocket costs after you’re reimbursed. But it may not cost as much as you think, and it may not be much more than if you see a participating provider. Still, it could be challenging if you’re on a fixed income.

For example, let’s say you’re seeing a physical therapist who accepts Medicare patients but not Medicare assignment. Medicare will pay $95 per visit to the provider; but your provider bills the service at $115. In most states, you’re responsible for a 15% limiting charge above $95. In this case, your bill would be 115% of $95, or $109.25.

Once you get your $95 reimbursement back from Medicare, your cost for the visit—the balance bill—would be $14.25 (plus any deductibles or copays) .

In some states, the maximum cap on the limiting charge is less than 15%. As mentioned earlier, New York state, for instance, allows only a 5% surcharge, which means that physical therapy appointment would cost you just $4.75 extra.

Bottom line: Medicare assignment providers and non-participating providers who agree to accept Medicare assignment are both viable options for patients. So if you want to see a particular provider, don’t rule them out just because they’re non-par.

While seeing a non-participating provider may still be affordable, ultimately, the biggest headache may be keeping track of claims and reimbursements, or simply setting aside the right amount of money to pay for your visit up front.

Before you schedule a visit, be sure to ask how much the service will cost. You can also estimate the payment amount based on Medicare-approved charges. A good place to start is this  out-of-pocket expense calculator  provided by the CMS.

What if I see a provider who opts out of Medicare altogether?

An opt-out provider will create a private contract with you, underscoring the terms of your agreement. But Medicare will not reimburse either of you for services.

Seeing a provider who does not accept Medicare will likely be more expensive. And your visits won’t count toward your deductible. But you may be able to work out paying reduced fees on a sliding scale for that provider’s services, all of which would be laid out in your contract.

What Does It Mean for a Doctor to Accept Medicare Assignment?

Written by: Malini Ghoshal, RPh, MS

Reviewed by: Malinda Cannon, Licensed Insurance Agent

Key Takeaways

Doctors who accept Medicare assignment are paid agreed-upon rates for services.

It’s important to verify that your doctor accepts assignment before receiving services to avoid high out-of-pocket costs.

A doctor or clinician may be “non-participating” but can still agree to accept Medicare assignment for some services.

If you visit a doctor or clinician who has opted out (doesn’t accept Medicare), you may have to pay for your entire visit cost unless it’s a medical emergency.

Medigap Supplemental insurance (Medigap) plans won’t pay for service costs from doctors who don’t accept assignment.

One of the things that Original Medicare beneficiaries often enjoy about their coverage is that they can use it anywhere in the country. Unlike plans with provider networks, they can visit doctors either at home or on the road; both are covered the same.

But do all doctors accept Medicare patients?

Truth is, this wide-ranging coverage area only applies to doctors who accept Medicare assignment. Fortunately, most do. If you’re eligible for Medicare, it’s important to visit doctors and clinicians who accept Medicare assignment. This will help keep your out-of-pocket costs within your control. Doctors who agree to accept Medicare assignment sign an agreement that they’re willing to accept payment from Medicare for their services.

If you’re a current beneficiary or nearing enrollment, you may have other questions. Do all doctors accept Medicare Advantage plans? What about Medicare Supplement insurance (Medigap)? Read on to learn how to find doctors that accept Medicare assignment and how this keeps your healthcare costs down.

Ready for a new Medicare Advantage plan?

What Is Medicare Assignment of Benefits?

When you’re eligible for Medicare, you have the option to visit doctors and clinicians who accept assignment. This means they are Medicare-approved providers who agree to receive Medicare reimbursement rates for covered services. This helps save you money.

If you have Original Medicare (Part A and B), your doctor visits are covered by your Part B plan. Inpatient services such as hospital stays and some skilled nursing care are covered by Part A .

In order for a participating doctor (or facility) to bill Medicare and be reimbursed, you must authorize Medicare to reimburse your doctor directly for your covered services. This is called the Medicare assignment of benefits. You transfer your right to receive Medicare payment for a covered service to your doctor or other provider.

Note: If you have a Medicare Supplement insurance ( Medigap ) plan to pay for out-of-pocket costs, you may also need to sign a separate assignment of benefits form for Medigap reimbursement. More on Medigap below.

How Can I Find Doctors Near Me That Accept Medicare?

There are several ways to find doctors and other clinicians who accept Medicare assignment close to you.

First, let’s take a look at the different types of Medicare providers.

They include:

Participating providers: Medicare-participating doctors and providers sign a participation agreement stating they will accept Medicare reimbursement rates for their services.

Non-participating providers:  Doctors or providers who are non-participating providers are eligible to accept Medicare assignment but haven’t signed a Medicare agreement. They may choose to accept assignment on a case-by-case basis. If you visit a non-participating provider, make sure to ask if they accept assignment for your particular service. Also get a copy of their fees. They will need to select “yes” on Centers for Medicare & Medicaid Services CMS Form 1500 to accept assignment for the service.

Opt-out providers:  Some doctors and other providers choose not to accept Medicare. If they choose to opt out, the period is two years (based on Medicare guidelines). The opt-out automatically renews if the provider doesn’t request a change in their status. You would be responsible for paying all costs for services received from an opt-out provider. You cannot bill Medicare for reimbursement unless the service was an urgent or emergency medical need. According to a report from KFF , roughly 1% of non-pediatric physicians opted out of Medicare in 2023.

Visiting a doctor who doesn’t accept assignment may cost you more. These providers can charge you up to 15% more than the Medicare-approved rate for a given service. This 15% charge is called the limiting charge. Some states limit this extra charge to a certain percent. This may also be called the Part B excess charge.

Here are some tips for finding doctors and providers who accept Medicare assignment:

• The easiest way to find a doctor who accepts Medicare assignment is to contact their office and ask them directly.
• If you’re looking for a new doctor, you can use the Medicare search tool to find clinicians and doctors that accept Medicare assignment.
• You can also ask a state health insurance assistance program (SHIP) representative for help in locating a doctor that accepts Medicare assignment.
• Don’t assume that having a longstanding relationship with your doctor means nothing will ever change. Check in with them to make sure they still accept Medicare assignment and whether they’re planning to opt out.

Note: Your doctor can choose to become a non-participating provider or opt out of participating in Medicare. It’s important to verify they accept Medicare assignment before receiving any services.

Find a local Medicare plan that fits your needs.

Do Doctors Who Accept Medicare Have to Accept Supplement Plans?

If your doctor accepts Medicare assignment and you have Original Medicare (Medicare Part A and Part B) with a Medicare Supplement (Medigap) plan, they will accept the supplemental insurance. Depending on your Medigap plan coverage , it may pay all or part of your out-of-pocket costs such as deductibles, copayments and coinsurance.

However, if you have a Medicare Advantage plan (Part C), you may have a network of covered doctors under the plan. If you visit an out-of-network doctor, you may need to pay all or part of the cost for your services.

Keep in mind that you can’t have a Medigap supplemental plan if you have a Medicare Advantage plan.

If you have questions or want to learn more about different Medicare plans like Original Medicare with Medigap versus Medicare Advantage, GoHealth has licensed insurance agents ready to help. They can shop your different options and offer impartial guidance where you need it.

Do Most Doctors Accept Medicare Advantage Plans?

Many doctors accept Medicare Advantage (Part C) plans, but these plans often use provider networks. These networks are groups of doctors and providers in an area that have agreed to treat an insurance company’s customers. If you have a Part C plan, you may be required to see in-network doctors with few exceptions. However, these types of plans are popular options for all-in-one coverage for your health needs. Plans must offer Part A and B coverage, plus a majority also include Part D , or prescription drug coverage. But whether a doctor accepts a Medicare Advantage plan may depend on where you live and the type of Medicare Advantage plan you have.

There are several types of Medicare Advantage plans including:

• Health Maintenance Organization (HMO): These plans have a network of covered providers, as well as a primary care physician to manage your care. If you visit a doctor outside your plan network, you may have to pay the full cost of your visit.
• Preferred Provider Organization (PPO): You’ll probably still have a primary care physician, but these are more flexible plans that allow you to go out of network in some cases. But you may have to pay more.
• Private Fee for Service (PFFS): You may be able to visit any doctor or provider with these plans, but your costs may be higher.
• Special Needs Plan (SNP): This type of plan is only for certain qualified individuals who either have a specific health condition ( C-SNP ) or who qualify for both Medicaid and Medicare insurance ( D-SNP ).

Have questions about your Medicare coverage?

What Are Medicare Assignment Codes?

Medicare assignment codes help Medicare pay for covered services. If your doctor or other provider accepts assignment and is a participating provider, they will file for reimbursement for services with a CMS-1500 form and the code will be “assigned.”

But non-participating providers can select “not assigned.” This means they are not accepting Medicare-assigned rates for a given service. They can charge up to 15% over the full Medicare rate for the service.

If you go to a doctor or provider who accepts assignment, you don’t need to file your own claim. Your doctor’s office will directly file with Medicare. Always check to make sure your doctor accepts assignment to avoid excess charges from your visit.

Health Insurance Claim Form . CMS.gov.

Lower costs with assignment . Medicare.gov.

How Many Physicians Have Opted-Out of the Medicare Program? KFF.org.

Joining a plan . Medicare.gov.

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Let's see if you're missing out on Medicare savings.

We just need a few details.

Related Articles

What Is Medicare IRMAA?

What Is an IRMAA in Medicare?

How to Report Medicare Fraud

Medicare Fraud Examples & How to Report Abuse

How to Change Your Address with Medicare

Reporting a Change of Address to Medicare

Can I Get Medicare if I’ve Never Worked?

Can You Get Medicare if You've Never Worked?

Why Are Some Medicare Advantage Plans Free?

Why Are Some Medicare Advantage Plans Free? $0 Premium Plans Explained

What Is Medicare Assignment?

Am I Enrolled in Medicare?

When and How Do I Enroll?

When and How Do I Enroll in Medicare?

Medicare Frequently Asked Questions

Let’s see if you qualify for Medicare savings today!

Speak with a Licensed Insurance Agent

• (888) 335-8996

Medicare Assignment

Home / Medicare 101 / Medicare Costs / Medicare Assignment

Summary: If a provider accepts Medicare assignment, they accept the Medicare-approved amount for a covered service. Though most providers accept assignment, not all do. In this article, we’ll explain the differences between participating, non-participating, and opt-out providers. You’ll also learn how to find physicians in your area who accept Medicare assignment. Estimated Read Time: 5 min

What is Medicare Assignment

Medicare assignment is an agreement by your doctor or other healthcare providers to accept the Medicare-approved amount as the full cost for a covered service. Providers who “accept assignment” bill Medicare directly for Part B-covered services and cannot charge you more than the applicable deductible and coinsurance.

Most healthcare providers who opt-in to Medicare accept assignment. In fact, CMS reported in its Medicare Participation for Calendar Year 2024 announcement that 98 percent of Medicare providers accepted assignment in 2023.

Providers who accept Medicare are divided into two groups: Participating providers and non-participating providers. Providers can decide annually whether they want to participate in Medicare assignment, or if they want to be non-participating.

Providers who do not accept Medicare Assignment can charge up to 15% above the Medicare-approved cost for a service. If this is the case, you will be responsible for the entire amount (up to 15%) above what Medicare covers.

Below, we’ll take a closer look at participating, non-participating, and opt-out physicians.

Medicare Participating Providers: Providers Who Accept Medicare Assignment

Healthcare providers who accept Medicare assignment are known as “participating providers”. To participate in Medicare assignment, a provider must enter an agreement with Medicare called the Participating Physician or Supplier Agreement. When a provider signs this agreement, they agree to accept the Medicare-approved charge as the full charge of the service. They cannot charge the beneficiary more than the applicable deductible and coinsurance for covered services.

Each year, providers can decide whether they want to be a participating or non-participating provider. Participating in Medicare assignment is not only beneficial to patients, but to providers as well. Participating providers get paid by Medicare directly, and when a participating provider bills Medicare, Medicare will automatically forward the claim information to Medicare Supplement insurers. This makes the billing process much easier on the provider’s end.

Medicare Non-Participating Providers: Providers Who Don’t Accept Assignment

Healthcare providers who are “non-participating” providers do not agree to accept assignment and can charge up to 15% over the Medicare-approved amount for a service. Non-participating Medicare providers still accept Medicare patients. However they have not agreed to accept the Medicare-approved cost as the full cost for their service.

Doctors who do not sign an assignment agreement with Medicare can still choose to accept assignment on a case-by-case basis. When non-participating providers do add on excess charges , they cannot charge more than 15% over the Medicare-approved amount. It’s worth noting that providers do not have to charge the maximum 15%; they may only charge 5% or 10% over the Medicare-approved amount.

When you receive a Medicare-covered service at a non-participating provider, you may need to pay the full amount at the time of your service; a claim will need to be submitted to Medicare for you to be reimbursed. Prior to receiving care, your provider should give you an Advanced Beneficiary Notice (ABN) to read and sign. This notice will detail the services you are receiving and their costs.

Non-participating providers should include a CMS-approved unassigned claim statement in the additional information section of your Advanced Beneficiary Notice. This statement will read:

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

This statement basically summarizes how excess charges work: Medicare will pay the Medicare-approved amount, but you may end up paying more than that.

Your provider should submit a claim to Medicare for any covered services, however, if they refuse to submit a claim, you can do so yourself by using CMS form 1490S .

Opt-Out Providers: What You Need to Know

Opt-out providers are different than non-participating providers because they completely opt out of Medicare. What does this mean for you? If you receive supplies or services from a provider who opted out of Medicare, Medicare will not pay for any of it (except for emergencies).

Physicians who opt-out of Medicare are even harder to find than non-participating providers. According to a report by KFF.org, only 1.1% of physicians opted out of Medicare in 2023. Of those who opted out, most are physicians in specialty fields such as psychiatry, plastic and reconstructive surgery, and neurology.

How to Find A Doctor Who Accepts Medicare Assignment

Finding a doctor who accepts Medicare patients and accepts Medicare assignment is generally easier than finding a provider who doesn’t accept assignment. As we mentioned above, of all the providers who accept Medicare patients, 98 percent accept assignment.

The easiest way to find a doctor or healthcare provider who accepts Medicare assignment is by visiting Medicare.gov and using their Compare Care Near You tool . When you search for providers in your area, the Care Compare tool will let you know whether a provider is a participating or non-participating provider.

If a provider is part of a group practice that involves multiple providers, then all providers in that group must have the same participation status. As an example, we have three doctors, Dr. Smith, Dr. Jones, and Dr. Shoemaker, who are all part of a group practice called “Health Care LLC”. The group decides to accept Medicare assignment and become a participating provider. Dr. Smith decides he does not want to accept assignment, however, because he is part of the “Health Care LLC” group, he must remain a participating provider.

Using Medicare’s Care Compare tool, you can select a group practice and see their participation status. You can then view all providers who are part of that group. This makes finding doctors who accept assignment even easier.

To ensure you don’t end up paying more out-of-pocket costs than you anticipated, it’s always a good idea to check with your provider if they are a participating Medicare provider. If you have questions regarding Medicare assignment or are having trouble determining whether a provider is a participating provider, you can contact Medicare directly at 1-800-633-4227. If you have questions about excess charges or other Medicare costs and would like to speak with a licensed insurance agent, you can contact us at the number above.

Announcement About Medicare Participation for Calendar Year 2024, Centers for Medicare & Medicaid Services. Accessed January 2024

https://www.cms.gov/files/document/medicare-participation-announcement.pdf

Annual Medicare Participation Announcement, CMS.gov. Accessed January 2024

https://www.cms.gov/medicare-participation

Does Your Provider Accept Medicare as Full Payment? Medicare.gov. Accessed January 2024

https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare

Kayla Hopkins

Ashlee Zareczny

• Medicare Eligibility Requirements
• Medicare Enrollment Documents
• Apply for Medicare While Working
• Guaranteed Issue Rights
• Medicare by State
• Web Stories
• Online Guides
• Calculators & Tools

© 2024 Apply for Medicare. All Rights Reserved.

Owned by: Elite Insurance Partners LLC. This website is not connected with the federal government or the federal Medicare program. The purpose of this website is the solicitation of insurance. We do not offer every plan available in your area. Currently we represent 26 organizations which offer 3,740 products in your area. Please contact Medicare.gov or 1-800-MEDICARE or your local State Health Insurance Program to get information on all of your options.

Let us help you find the right Medicare plans today!

Simply enter your zip code below

Medicare Assignment: Understanding How It Works

Medicare assignment is a term used to describe how a healthcare provider agrees to accept the Medicare-approved amount. Depending on how you get your Medicare coverage, it could be essential to understand what it means and how it can affect you.

What is Medicare assignment?

Medicare sets a fixed cost to pay for every benefit they cover. This amount is called Medicare assignment.

You have the largest healthcare provider network with over 800,000 providers nationwide on Original Medicare . You can see any doctor nationwide that accepts Medicare.

Understanding the differences between your cost and the difference between accepting Medicare and accepting Medicare assignment could be worth thousands of dollars.

Doctors that accept Medicare

Your healthcare provider can fall into one of three categories:

Medicare participating provider and Medicare assignment

Medicare participating providers not accepting medicare assignment, medicare non-participating provider.

More than 97% of healthcare providers nationwide accept Medicare. Because of this, you can see almost any provider throughout the United States without needing referrals.

Let’s discuss the three categories the healthcare providers fall into.

Participating providers are doctors or healthcare providers who accept assignment. This means they will never charge more than the Medicare-approved amount.

Some non-participating providers accept Medicare but not Medicare assignment. This means you can see them the same way a provider accepts assignment.

You need to understand that since they don’t take the assigned amount, they can charge up to 15% more than the Medicare-approved amount.

Since Medicare will only pay the Medicare-approved amount, you’ll be responsible for these charges. The 15% overcharge is called an excess charge. A few states don’t allow or limit the amount or services of the excess charges. Only about 5% of providers charge excess charges.

Opt-out providers don’t accept Original Medicare, and these healthcare providers are in the minority in the United States. If healthcare providers don’t accept Medicare, they won’t be paid by Medicare.

This means choosing to see a provider that doesn’t accept Medicare will leave you responsible for 100% of what they charge you. These providers may be in-network for a Medicare Advantage plan in some cases.

Avoiding excess charges

Excess charges could be large or small depending on the service and the Medicare-approved amount. Avoiding these is easy. The simplest way is to ask your provider if they accept assignment before service.

If they say yes, they don’t issue excess charges. Or, on Medicare.gov , a provider search tool will allow you to look up your healthcare provider and show if they accept Medicare assignment or not.

Medicare Supplement and Medicare assignment

Medigap plans are additional insurance that helps cover your Medicare cost-share . If you are on specific plans, they’ll pay any extra costs from healthcare providers that accept Medicare but not Medicare assigned amount. Most Medicare Supplement plans don’t cover the excess charges.

The top three Medicare Supplement plans cover excess charges if you use a provider that accepts Medicare but not Medicare assignment.

Medicare Advantage and Medicare assignment

Medicare assignment does not affect Medicare Advantage plans since Medicare Advantage is just another way to receive your Medicare benefits. Since your Medicare Advantage plan handles your healthcare benefits, they set the terms.

Most Medicare Advantage plans require you to use network providers. If you go out of the network, you may pay more. If you’re on an HMO, you’d be responsible for the entire charge of the provider not being in the network.

Do all doctors accept Medicare Supplement plans?

All doctors that accept Original Medicare accept Medicare Supplement plans. Some doctors don’t accept Medicare. In this case, those doctors won’t accept Medicare Supplements.

Where can I find doctors who accept Medicare assignment?

Medicare has a physician finder tool that will show if a healthcare provider participates in Medicare and accepts Medicare assignments. Most doctors nationwide do accept assignment and therefore don’t charge the Part B excess charges.

Why do some doctors not accept Medicare?

Some doctors are called concierge doctors. These doctors don’t accept any insurance and require cash payments.

What is a Medicare assignment?

Accepting Medicare assignment means that the healthcare provider has agreed only to charge the approved amount for procedures and services.

What does it mean if a doctor does not accept Medicare assignment?

The doctor can change more than the Medicare-approved amount for procedures and services. You could be responsible for up to a 15% excess charge.

How many doctors accept Medicare assignment?

About 97% of doctors agree to accept assignment nationwide.

Is accepting Medicare the same as accepting Medicare assignment?

No. If a doctor accepts Medicare and accepts Medicare assigned amount, they’ll take what Medicare approves as payment in full.

If they accept Medicare but not Medicare assignment, they can charge an excess charge of up to 15% above the Medicare-approved amount. You could be responsible for this excess charge.

What is the Medicare-approved amount?

The Medicare-approved amount is Medicare’s charge as the maximum for any given medical service or procedure. Medicare has set forth an approved amount for every covered item or service.

Can doctors balance bill patients?

Yes, if that doctor is a Medicare participating provider not accepting Medicare assigned amount. The provider may bill up to 15% more than the Medicare-approved amount.

What happens if a doctor does not accept Medicare?

Doctors that don’t accept Medicare will require you to pay their full cost when using their services. Since these providers are non-participating, Medicare will not pay or reimburse for any services rendered.

Get help avoiding Medicare Part B excess charges

Whether it’s Medicare assignment, or anything related to Medicare, we have licensed agents that specialize in this field standing by to assist.

Give us a call, or fill out our online request form . We are happy to help answer questions, review options, and guide you through the process.

Related Articles

• What are Medicare Part B Excess Charges?
• How to File a Medicare Reimbursement Claim?
• Medicare Defined Coinsurance: How it Works?
• Welcome to Medicare Visit
• Guide to the Medicare Program

CALL NOW (833) 972-1339

Medicare Interactive Medicare answers at your fingertips -->

Participating, non-participating, and opt-out providers, outpatient provider services.

You must be logged in to bookmark pages.

Email Address * Required

Password * Required

Lost your password?

If you have Original Medicare , your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of provider, meaning three different relationships a provider can have with Medicare . A provider’s type determines how much you will pay for Part B -covered services.

• These providers are required to submit a bill (file a claim ) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem .
• If you see a participating provider , you are responsible for paying a 20% coinsurance for Medicare-covered services.
• Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.
• Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge ). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services.
• Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP) .
• If you pay the full cost of your care up front, your provider should still submit a bill to Medicare. Afterward, you should receive from Medicare a Medicare Summary Notice (MSN) and reimbursement for 80% of the Medicare-approved amount .
• The limiting charge rules do not apply to durable medical equipment (DME) suppliers . Be sure to learn about the different rules that apply when receiving services from a DME supplier .
• Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care.
• The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.
• Opt-out providers do not bill Medicare for services you receive.
• Many psychiatrists opt out of Medicare.

Providers who take assignment should submit a bill to a Medicare Administrative Contractor (MAC) within one calendar year of the date you received care. If your provider misses the filing deadline, they cannot bill Medicare for the care they provided to you. However, they can still charge you a 20% coinsurance and any applicable deductible amount.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool .

Update your browser to view this website correctly. Update my browser now

Medicare Providers: Accept Medicare Assignment vs. Accept Medicare Patients

Now that you are enrolled in Medicare, you need to know which doctors allow you to utilize your benefits to the fullest. In order to maximize your benefits, you need to receive care from doctors who accept Medicare assignment.

Many people don’t realize that there are big differences between providers who accept Medicare assignment and providers who accept Medicare patients. In this article, we will discuss the differences and how they apply to your Medicare coverage.

You did your homework. You called your doctor’s office and asked if they took Medicare. The receptionist confirmed that yes, the office accepts Medicare patients. 

You think, “Great!” and schedule an appointment.

You go to your appointment that you think is mostly covered by Original Medicare. You plan to pay your copay, but nothing more.

And then a bill arrives in the mail. The amount due is more than your copay is supposed to be. You call the office, thinking there must have been a mistake.

The receptionist tells you that it is not a mistake. Their office accepts Medicare patients and files the claim on the individual’s behalf, but they do not accept Medicare assignment. You’re stuck paying a bill you weren’t expecting.

What went wrong? Did the office lie to you?

Not quite, although it would have been much more helpful if the receptionist had explained the differences between “accepting Medicare patients” and “accepting Medicare assignment.”

Providers Accepting Medicare Assignment vs. Providers Accepting Medicare Patients

Here’s the difference.

Accepting Medicare assignment means the provider will accept Medicare’s payment – negotiated fee considered fair by both parties. That means you won’t be paying more than what your Medicare plan has decided is necessary to provide coverage for medical services and supplies. This applies to procedures covered under Medicare Part B.

The catch is, even a doctor who does not accept Medicare assignment can provide services for a Medicare beneficiary. Many will also file the claim for their patient. However, if they do not accept Medicare assignment, they are allowed to charge up to 15% more than Medicare’s allowed fee. These are called Medicare overcharges or “Part B excess charges.” Excess charges occur when providers bill their patients for more than what Medicare has agreed to pay the provider.

For example, let’s say you go to the doctor and have a Medicare-approved procedure that costs $100 (according to Medicare.)

If that doctor does not accept Medicare assignment, they can decide that $100 is not sufficient reimbursement for that test. The doctor can choose to charge 15% more, which would amount to $15 ($115 total) for the test. This $15 is considered the Part B excess charge.

Which Doctors Accept Medicare?

The only way to prevent excess charges is to ask your doctor if they accept Medicare assignment. Make sure you use that term specifically and do not just ask, “Do you take Medicare?”

If you are scheduling a bigger procedure like a surgery, there is likely more than one doctor involved – like an anesthesiologist. Be sure to ask if all the providers on your care team accept Medicare assignment. It’s often the specialists that members forget to ask about.

The good news is, 95% of the doctors across the United States accept Medicare assignment. For that reason, excess charges are rare in most parts of the country.

Other Options to Prevent Excess Charges

Another option to ensure you do not pay Part B excess charges is to enroll in a Medicare Supplement (Medigap plan) or Medicare Advantage (Part C) plan that covers those extra charges for you.

Providers Who Opt-Out of Medicare

There are providers who have completely opted out of the Medicare system. If you see a doctor who has done this, neither the provider nor you will send a claim to Medicare as there will be absolutely no coverage for services rendered. You will pay the provider the full fee for their services. (Which can far exceed the extra 15%.)

Any easy way to find out if your provider has opted out of Medicare is to search the national database on Medicare.gov.

One Last Consideration

If you decide to enroll in a Part C plan , you will need to find out if you must receive care from an in-network provider. This is a separate qualification than accepting Medicare assignment.

Some plans only allow you to see in-network providers, otherwise, you may have no coverage if you go outside of your network. Others offer partial coverage for out-of-network services.

Again, be specific when you’re asking your provider this question. Don’t ask, “Do you take Company X patients?” Instead ask, “Are you in-network with Company X?” This will ensure you get the answer you are looking for and don’t end up with surprises later.

Medigap plans allow you to see any provider, as long as they accept Medicare assignment.

Fortunately, doctors who do not accept Medicare assignment are rare. However, medical bills can quickly pile up, so doing your homework in regards to your healthcare team is an important component to controlling the cost of your healthcare.

Dani Dinkel

Dani is a licensed health and life insurance advisor. She is also the creator of everything you see on our social media accounts and runs Blaze Creative, a content-writing and copywriting agency designed specifically for Medicare brokers.

Leave a Comment Cancel Reply

The independent source for health policy research, polling, and news.

What to Know About How Medicare Pays Physicians

Alex Cottrill , Juliette Cubanski , and Tricia Neuman Published: Mar 06, 2024

More than 65 million people— nearly 20% of the U.S. population —receive their health insurance coverage through the federal Medicare program. In 2021, Medicare spending comprised one-fifth (21%) of national health care spending and 13% of the federal budget . The largest share of total Medicare spending ( 48% in 2021 ) is dedicated to Part B services, including physician services, outpatient services, and physician-administered drugs, and accounts for 26% of national payments for physician and clinical services.

Each year, the Centers for Medicare and Medicaid Services (CMS) updates Medicare payments to physicians and other clinicians through rulemaking, based on parameters established under law. In November 2023, CMS finalized a 3.4% decrease in the physician fee schedule conversion factor, a key aspect of payment rates under the Medicare program, resulting in a 1.25% decrease in overall payments that is expected to vary by specialty . These changes, along with several others, went into effect on January 1, 2024 (Figure 1). Congress is expected to vote on legislation that would mitigate these payment reductions temporarily, from March 9, 2024 through the remainder of the year.

Figure 1: Timeline of Major Provisions Impacting the Medicare Physician Fee Schedule

Physician and other professional groups, including the American Medical Association, the Medical Group Management Association, and the American Hospital Association, have opposed the payment cuts and expressed concerns that loss of revenue could push physicians to opt out of the Medicare program, leading to access problems for Medicare beneficiaries. Physicians are not required to take Medicare patients, but most do; just 1% opted out of the program in 2023.

The new legislation that adjusts physician payments through the remainder of the year is one of several recent proposals from policymakers aimed at canceling out or mitigating these payment reductions. Since 2020, Congress has enacted four temporary, one-year increases to physician payment rates to avoid reductions in fees. Others, including MedPAC , have proposed broader changes to address concerns with the current payment system. A bipartisan group of senators recently announced the formation of a Medicare payment reform working group, with the goal of investigating long-term reforms to the physician fee schedule, and additional legislation is expected later in the year.

This issue brief answers key questions about how physicians are paid under the Medicare program, and reviews policy options under discussion for payment reform. The brief is focused primarily on the physician payment system used in traditional Medicare, as Medicare Advantage plans have flexibility to pay providers differently; currently there is no information on how much Medicare Advantage plans pay providers. (See Appendix for a glossary of relevant programs, legislation, and terms.)

1. What is the Medicare physician fee schedule?

Medicare reimburses physicians and other clinicians based on the physician fee schedule , which assigns payment rates for more than 10,000 health care services , such as office visits, diagnostic procedures, or surgical procedures. For services provided to traditional Medicare beneficiaries, Medicare typically pays the provider 80% of the fee schedule amount, with the beneficiary responsible for a maximum of 20% in coinsurance. Physicians who participate in Medicare agree to accept this arrangement as payment in full (known as accepting “assignment”) for all Medicare covered services. Others, known as non-participating physicians, may accept “assignment” on a claim-by-claim basis and may choose to bill for larger amounts by charging additional coinsurance, up to a limit. Physicians who opt out of the program altogether enter into private contracts with their Medicare patients, are not limited to charging fee schedule amounts, and do not receive any reimbursement from Medicare.

Fee schedule rates for a given service are based on a weighted sum of three components: clinician work, practice expenses, and professional liability insurance (also known as medical malpractice insurance), measured in terms of relative value units (RVUs). Together these three components represent the overall cost and effort associated with a given service, with more costly or time-intensive services receiving a higher weighted sum. Each component is adjusted to account for geographic differences in input costs, and the result is multiplied by the fee schedule conversion factor (an annually adjusted scaling factor that converts numerical RVUs into payment amounts in dollars).

Payment rates specified under the physician fee schedule establish a baseline amount that Medicare will pay for a given service, but payments may be adjusted based on other factors, such as the site of service, the type of clinician providing the service, and whether the service was provided in a designated health professional shortage area . Physicians can also receive quality-based payment adjustments under the Quality Payment Program (QPP) (see question 6).

2. How does Medicare update physician payment rates?

Annual updates to the physician fee schedule include statutorily-required updates to the conversion factor under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (see question 5), as well as other adjustments to reflect the addition of new services, changes in input costs for existing services, and other factors. A multispecialty committee of physicians and other professionals, known as the AMA/Specialty Society RVS Update Committee (RUC) , issues annual recommendations to advise CMS on the weighting of new or revised service codes.

Under current law, the projected cost of all changes to the physician fee schedule must be budget neutral, that is, the changes may not raise total Medicare spending by more than $20 million in a given year. This requirement was established by the Omnibus Budget Reconciliation Act of 1989 to address concerns that constraints on physician fees for specific services would lead to increases in service volume, potentially driving growth in Medicare spending for physician services over time. The law requires CMS to adjust fee schedule spending when projected costs exceed the threshold, typically by decreasing the conversion factor relative to the statutory update called for by MACRA.

3. How have physician payment rates changed in 2024?

CMS recently finalized payment changes for 2024, including increases in payment for a range of services related to primary care, behavioral health, and direct patient care, among others (see question 4). Due to the statutory requirement under the Omnibus Budget Reconciliation Act of 1989 that CMS preserve budget neutrality when adjusting physician payment rates, these service-specific increases necessitated a decrease to the fee schedule conversion factor to offset additional costs. Budget neutrality adjustments are made separately from statutory adjustments under MACRA and any temporary payments provided by Congress, both of which may also impact the conversion factor in a given year.

The 3.4% decrease to the conversion factor finalized for 2024 reflects the following adjustments to these three factors: (1) a -2.18% budget neutrality adjustment, (2) a 0% statutory increase under MACRA for 2024, and (3) -1.25% reduction in temporary payments provided by Congress for 2024 under the Consolidated Appropriations Act of 2023 .

The combined impact of these changes is a -1.25% decrease in overall payments under the physician fee schedule relative to 2023, according to CMS. Payment changes are expected to vary by specialty , however. For example, clinicians most directly impacted by service-specific changes, such as those in primary care and behavioral health, are projected to see a net increase in payments, while clinicians in radiology, physical and occupational therapy, and some surgical specialties are projected to see the largest net decrease.

Congress is expected to vote on pending legislation which would mitigate the 3.4% decrease to the fee schedule conversion factor, a change which is expected to result in a modest increase to physician payment rates across all specialties, relative to current law.

4. What other changes have been finalized by CMS for 2024?

Many of the provisions in the physician fee schedule final rule for 2024 are part of a wider effort by CMS and the Department of Health and Human Services (HHS) to improve health equity and increase support for primary care services, addressing long-standing concerns about the gap in compensation between primary and specialty care physicians (see question 7). CMS has also implemented two provisions of the Consolidated Appropriations Act of 2023 , which expand Medicare coverage for a range of behavioral health services. The final payment rule for 2024 includes the following key changes:

• CMS has added new billing codes to the physician fee schedule, allowing clinicians to bill separately for time dedicated to care coordination and direct patient care services, such as caregiver training, assessment of health-related social needs, and coordination with community health workers, care navigators, and peer support specialists.
• CMS has added a new add-on payment that allows clinicians to bill at higher rates for evaluation and management visits deemed to be complex, such as visits that are central to coordinating all of a patient’s needed health services or part of treatment for a serious, ongoing health condition.
• CMS has added new billing codes related to psychotherapy for crisis services, and existing codes can be billed by a broader range of providers. Additionally, new types of behavioral health providers, such as mental health counselors (MHCs) and marriage and family therapists (MFTs) can now bill for reimbursement under the physician fee schedule, following legislation passed under the Consolidated Appropriations Act of 2023 .
• CMS has extended several telehealth flexibilities that were granted on a temporary basis during the COVID-19 pandemic through the end of 2024, including provisions that allow Medicare beneficiaries to receive telehealth services from any site, including their home, delay the requirement for an in-person visit within six months of initiating mental or behavioral telehealth services, and allow telehealth services to be offered by Rural Health Clinics and Federally Qualified Health Centers .
• CMS has added health and well-being coaching to the Medicare Telehealth Services list through the end of 2024, and Social Determinants of Health Risk Assessments have been added on a permanent basis. Finally, CMS has expanded the definition of covered telehealth practitioners to include qualified occupational therapists, physical therapists, speech-language pathologists, and audiologists.

The new rules also include updates to the Medicare Shared Savings Program (MSSP) , as well as other changes related to payment for opioid treatment programs, preventive vaccine administration, and a variety of other health services.

5. How have Medicare payments to physicians evolved over time?

Medicare has revised its system of payment for physician services numerous times over the years (Figure 1). The current payment system was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) , which included a schedule for annual, statutorily-defined updates to the conversion factor, a key determinant of payment rates under the physician fee schedule. These updates are set by legislation and do not vary based on underlying economic conditions. However, further adjustments to preserve budget neutrality and supplemental payments provided by Congress may result in conversion factor updates that are higher or lower than the statutory update in a given year.

The physician payment framework established by MACRA was intended to stabilize fluctuations in payment caused by the prior payment system under the Medicare Sustainable Growth Rate (SGR) formula , which set annual targets for Medicare physician spending based on growth in the gross domestic product (GDP). Under the SGR, if spending exceeded its target in a given year, payment rates would be cut the following year, while spending that was below the target led to increased rates. As with the current system, rates were subject to further adjustment for budget neutrality if the projected cost of all fee schedule spending increased by more than $20 million for the year.

The SGR was established by the Balanced Budget Act of 1997 to slow the growth in Medicare spending for physician services, but the formula garnered criticism , as growth in service volume and rising costs led to several years of spending that exceeded the growth target, necessitating payment cuts from 2002 onward. Between 2002 and 2015, Congress enacted 17 short-term interventions (so-called “doc-fixes”) to delay the cuts and provide temporary increases to physician payments, but did so without repealing the SGR, which resulted in accumulated deficits over time.

MACRA permanently eliminated the SGR formula, preventing a 21.2% cut in physician fees slated for 2015 and replacing it with 0% statutory increases to the conversion factor through 2025 (later raised to 0.5% from 2016-2019), followed by modest annual increases from 2026 onward. While overall payments were not scheduled to increase for the first decade of MACRA’s operation, the legislation also included new pathways to allow for payment increases through bonus payments and quality-based payment adjustments under the Quality Payment Program (QPP) (see question 6).

Although MACRA has stabilized payments under the physician fee schedule to some degree, rates have continued to fluctuate over the last decade. Since 2020, Congress has provided four temporary, one-year increases to fee schedule rates to boost payment during the COVID-19 pandemic and offset prior budget-neutrality cuts, raising concerns that the cycle of “doc-fixes” under the SGR formula has not been wholly fixed (see question 7).

6. How does the QPP factor into physician payments?

The Quality Payment Program (QPP) was established by MACRA in 2015 to create financial incentives for health care providers to control costs and improve care quality. Under the QPP, physicians and other clinicians who participate in qualified advanced alternative payment models (A-APMs) , such as select accountable care organizations (ACOs) and others , are eligible for bonus payments if they meet certain participation thresholds. A-APMs are a type of value-based care model in which the provider bears some financial risk for the costs of care, typically by sharing in a portion of financial savings and losses relative to a benchmark. Qualifying A-APM clinicians receive an annual 5% bonus through 2024, which will be lowered to 3.5% in 2025, and replaced with an annual 0.75% increase to the conversion factor beginning in 2026 (relative to a 0.25% increase for all other clinicians). Roughly 240,000 clinicians received this bonus in 2022, based on participation during the 2020 payment year.

Clinicians who do not participate in A-APMs, or do not meet the participation criteria for A-APM bonus payments, are subject to additional reporting requirements under the Merit-based Incentive Payment System (MIPS) , which adjusts payments up or down depending on a clinician’s performance on certain quality metrics. Clinicians are required to participate in MIPS if they are eligible, but many are exempt , such as those in certain specialties (e.g., podiatrists), those in their first year of Medicare participation, and those who serve a low volume of Medicare patients. Roughly half of all Medicare Part B providers (49%) were eligible for MIPS in 2019.

Payment adjustments under MIPS are capped each year ( between +9% and -9% in 2022 ), and savings generated from clinicians who incur negative adjustments are used to fund positive adjustments for those who qualify. Because a relatively small share of clinicians have incurred negative adjustments each year since MIPS was implemented, positive adjustments have generally been much lower than the annual cap. In 2022, roughly 850,000 clinicians received positive adjustments up to 1.87%, while just 19,000 clinicians received negative adjustments down to -9%.

7. What concerns have been raised about the current payment system?

Criticism of the recent payment cuts under the physician fee schedule has focused on three primary concerns about the way in which Medicare pays physicians and other clinicians. These include: (1) the overall adequacy of Medicare payments to cover medical practice costs and incentivize participation in the Medicare program, (2) the gap in compensation between primary and specialty care clinicians, and (3) the success of the QPP at achieving its goal of incentivizing quality improvements and cost-efficient spending.

Payment Adequacy: Physician groups and others have expressed concern that certain aspects of the current payment system, such as the requirement for budget neutrality under the physician fee schedule and the limited flexibility of conversion factor updates under MACRA, have resulted in payment rates that are too low to keep up with inflation in medical practice costs. Practice expenses are one component of the relative-value calculation used to determine payment rates for fee schedule services, but the need to preserve budget neutrality makes it difficult for CMS to increase payment for some services without also decreasing payment in other areas, such as by lowering the fee schedule conversion factor.

Physician groups and others have pointed out that statutory increases to the conversion factor under MACRA are not scheduled to begin until 2026, and do not vary based on underlying economic conditions. Further, a prior KFF review of the literature has shown that Medicare pays less for physician services , on average, than private insurers, leading physician groups and some policymakers to warn about potential access issues for beneficiaries that could result if physicians are driven to opt out of the Medicare program in the future due to payment rates.

However, access problems for beneficiaries have generally not materialized to date. According to MedPAC, Medicare beneficiaries report access to clinician services that is equal to, or better than , that of privately insured individuals. A recent KFF analysis found that just 1% of all non-pediatric physicians had opted out of the Medicare program in 2023, suggesting that the current fee structure has not substantially discouraged participation. Moreover, MedPAC estimates that virtually all Medicare claims (99.7% in 2021) are accepted on “assignment” and paid at the standard rate, with beneficiaries in traditional Medicare facing no more than the standard 20% coinsurance rate.

Primary Care Compensation: A second concern with the current payment system is that Medicare does not adequately pay for primary care services, as reflected by the gap in Medicare payments between primary and specialty care clinicians. Payments under the physician fee schedule are generally higher for procedures (e.g., surgeries) than non-procedural services (e.g., evaluation and management). MedPAC has expressed concern that this imbalance encourages clinicians to focus on more costly and profitable services at the expense of high-value, but less profitable, services, such as patient education, preventive care, and coordination across care teams, which leads to higher physician spending over time.

Role of the QPP: QPP programs such as MIPS and bonus payments for A-APM clinicians are designed to create incentives for quality improvements, care coordination, and high-value services. While the share of clinicians who qualify for A-APM bonuses has increased substantially since the QPP began (from roughly 99,000 in 2017 to 271,000 in 2021), some policymakers have argued that greater incentives are needed to encourage providers to take on the financial risks and high startup costs associated with these models. Additionally, MedPAC has expressed concern that MIPS, the quality-based payment program for clinicians who do not participate in A-APMs, does not give providers enough incentives to improve quality and control costs. As noted earlier, a large share of clinicians are exempt from the program, and because few participants receive negative adjustments, positive adjustments are relatively modest .

8. What policy proposals have been put forward to address concerns with the current physician payment system?

In addition to legislation that directly addresses the 2024 payment cuts, policymakers and others have put forward a number of strategies to revise the current physician payment system. These include measures to prevent fluctuations in payment from year to year, provide additional support to primary care and safety-net providers, and create stronger incentives for efficient spending, care coordination, and participation in A-APMs.

Several bills have been introduced in Congress that would raise or modify the budget neutrality threshold, allowing CMS greater flexibility to adjust payment rates to reflect evolving policy priorities without necessitating a mandatory payment cut. For example, legislation has been introduced that would provide regular updates to the budget neutrality threshold based on growth in the Medicare Economic Index (MEI), a measure of inflation in the prices of goods and services used by clinicians to provide care. Further, a bipartisan coalition of physicians in Congress recently introduced the Strengthening Medicare for Patients and Providers Act , which would tie annual updates to the fee schedule’s conversion factor to the annual percentage increase in the MEI.

In 2023, MedPAC also recommended a one-time inflation-based increase to physician payment rates in 2024 (equal to 50% of the projected increase in the MEI), but has not recommended annual updates for inflation, focusing instead on targeted strategies to bolster payments to primary care clinicians and safety-net providers. Their recommendations include a permanent add-on payment for services provided to low-income Medicare beneficiaries, raising payment in these instances by 15% for claims billed by primary care clinicians and 5% for claims billed by non-primary care clinicians.

MedPAC has voiced support for the goals behind MACRA and the QPP, including the financial incentives offered to A-APM participants under current law. At the same time, MedPAC has recommended significant changes to the design of the QPP, including the elimination of MIPS, based on concerns that it does not give providers enough incentives to make significant practice improvements. In its place, MedPAC has recommended a voluntary program designed to mimic the structure of A-APMs and other alternative payment models , allowing clinicians to transition into these models more gradually. Finally, some policymakers have introduced legislation that would extend bonus payments for qualifying A-APM clinicians though the end of 2026.

In addition to these more targeted proposals, a bipartisan group of senators recently announced the formation of a Medicare payment reform working group, which will investigate long-term reforms to the physician fee schedule and updates to the physician payment legislation provided by MACRA.

Not yet 10 years out from the passage of MACRA, these measures suggest growing interest in Medicare physician payment reform, beyond addressing the physician fee cuts finalized for 2024. Designing payment approaches that address concerns raised by interested parties to compensate physicians adequately while restraining spending growth represents a challenge for policymakers.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

• Health Costs
• Federal Budget
• Access to Care

Also of Interest

• Five Things to Know About Medicare Site-Neutral Payment Reforms
• How Many Physicians Have Opted Out of the Medicare Program?
• What to Know About Medicare Part D Premiums

OLYMPICS ALERT: US women win 4x100 Olympic relay giving anchor Sha'carri Richardson her first Olympic gold medal

NEWS ALERT: Man who attacked police with poles at US Capitol gets 20 years in prison, one of the longest sentences in Jan. 6 riot

How to Use Medicare’s Telehealth Coverage

U.S. News & World Report

August 8, 2024, 8:00 PM

• Share This:
• share on facebook
• share on threads
• share on linkedin
• share on email

Wouldn’t it be great if you didn’t have to physically go to a doctor’s office every time you got sick?

In this day and age, that dream is now a reality for Medicare beneficiaries, thanks to Medicare’s telehealth coverage.

What Is Medicare’s Telehealth Coverage?

Telehealth, which is a way to visit with your provider using a phone or video call, is a benefit available to all Medicare members. It’s recently gained traction in many health care circles.

“A lot of Medicare beneficiaries got their first taste of telehealth care during the COVID pandemic, and some came to really depend on it,” says Whitney Stidom, vice president of sales and operations with eHealth Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.

Rules were relaxed during the worst of the COVID-19 pandemic to allow for broader coverage of telehealth services under Medicare Part B , she adds, and that opened up telehealth access to many more people around the country. Both providers and beneficiaries appreciated this additional means of working together, and Medicare has since made telehealth coverage an ongoing benefit.

What’s more, Medicare beneficiaries enrolled in a Medicare Advantage plan may have additional telehealth benefits, such as urgent care visits, Stidom says, but these benefits can vary from one plan to another. If you’ve got Medicare Advantage, ask your insurer for more information about your telehealth coverage.

[ Read: A Beginner’s Guide to a Virtual Doctor’s Visit. ]

How to Access Telehealth

You can connect with your provider for a telehealth visit via a few clicks on an electronic device, such as a computer, smartphone or tablet, says Dr. Steven Arabo , medical director of Medicare programs for CalOptima Health, which provides health insurance coverage to low-income populations in Orange County, California.

Your provider will send a link to access your visit remotely via your computer or smartphone. At the appointed time, click the link, follow the instructions on the screen and you’ll be connected to your provider.

If your telehealth visit is provided as an audio-only call, connecting may be as simple as answering the phone when it rings.

Telehealth is a benefit available to all Medicare members.

“There are no geographic restrictions for patients or providers, therefore telehealth services are available in all 50 states,” Arabo says.

Just note that telehealth may not be appropriate for all visits and all situations, such as when you might need to undergo physical tests.

Before starting a telehealth call, make sure you have on hand a list of all the medications you’re taking or the bottles themselves. Come prepared with questions or talking points to ensure you make the most of your time on the call.

[ Read: Medicare vs. Medicare Advantage: How to Choose. ]

How Much Does Medicare’s Telehealth Cost?

After you meet the Part B deductible (which, in 2024, is $240), you’ll pay 20% of the Medicare-approved amount for telehealth visits, according to the Centers for Medicare and Medicaid Services. The Medicare-approved amount is the payment set by original Medicare ( Parts A and B ) for a covered service or item. When your provider accepts the assignment to treat you, Medicare pays its share and then you pay your share of that amount for the doctor or other health care provider’s services.

In most cases, telehealth services cost the same as if the care had been rendered in person. If price is a concern, ask your provider for details on what the services will cost. The specific amount you’ll owe depends on a variety of factors:

— How much the doctor charges for the services rendered

— Whether your doctor accepts Medicare payment

— Whether you have another insurance policy that might cover part of the cost

— In which part of the country services are rendered

[ Read: What Medicare Doesn’t Cover and How to Manage Costs ]

What Can Telehealth Be Used For?

Telehealth visits can be used for patients who don’t require a physical exam, Arabo says. As such, it can be a good option for many small issues, ranging from headaches and the common cold to an upset stomach.

“Telehealth visits can also be used for checking results from lab tests or X-rays, checking in with your provider after surgery and getting assistance with medication management,” Arabo adds.

It’s important to note that some of the expanded coverage that arose from the COVID-19 pandemic will expire after December 31, 2024. So, if you’ve used telehealth recently, be forewarned that some services you’ve accessed remotely before may not be covered next year. For example, Medicare Part B will no longer cover telehealth services for physical or occupational therapy or for speech therapy — unless you live in a rural area, Stidom notes.

Also after December 31, 2024, whether you live in a rural area or not, Medicare Part B will continue to cover telehealth for these services:

— Diabetes self-management training

— Substance abuse treatment

— Some mental health care services

— Some services related to treatment of a stroke

— Medicare nutrition therapy

— Monthly end-stage renal disease visits for home dialysis

If you’d like to use telehealth, ask your provider if it’s available for the care you need.

While telehealth can be a great option for many people and can address a wide range of health concerns, it can’t address all of your medical needs, Stidom notes.

“Sometimes you just need to be physically present with the doctor for proper diagnosis or treatment or for certain tests to be administered,” she says.

For example, no matter how advanced your smartphone technology, it won’t be able to draw blood from you remotely. And for other more complex diagnoses, your provider may insist on an in-person exam.

More from U.S. News

8 Questions to Ask a Geriatrician at Your First Appointment

6 Routine Health Screenings Everyone Needs

What Makes a Good Doctor: Qualities to Look For

How to Use Medicare?s Telehealth Coverage originally appeared on usnews.com

Related News

Meet the press? Hold that thought. The candidate sit-down interview ain’t what it used to be

Body camera footage shows local police anger at Secret Service after Trump assassination attempt

The threat Israel didn’t foresee: Hezbollah’s growing drone power

Recommended.

Debby cleanup: Tree topples into house in Montgomery Co.; heavy rain leads to major flooding in Annapolis

Fire breaks out overnight at Montgomery County church, causing more than $5 million in damages

Man who attacked police at the US Capitol with poles gets 20 years, one of longest Jan. 6 sentences

Related categories:.

• Federal Advocacy
• State Advocacy
• Patient Protection
• Third Party

Bill seeks better fix to Medicare Physician Fee Schedule cuts

In an effort to reform Medicare funding and avert painful cuts to physician reimbursements for services, a bipartisan Senate bill introduced Aug. 1 would increase the agency’s budget neutrality threshold to $53 million.

The threshold, last updated in 1992, would also automatically increase every five years to keep pace with the Medicare Economic Index. Currently, Medicare is obliged to offset or neutralize proposed increases in one part of its budget with spending cuts in another. Medicare reimburses doctors for medical services. The threshold is currently $20 million.

The bill, S. 4935 , was introduced by Sens. John Boozman, R-Ark., and Peter Welch, D-Vt., along with Sens. Thom Tillis, R-N.C., Angus King, I-Maine, Roger Marshall, R-Kansas, and Jeanne Shaheen, D-N.H.

Says AOA President Steven T. Reed, O.D.: “We applaud Sens. Boozman and Welch for the visionary direction S. 4935 sets for future growth of health care access. For so many years, physicians of all types, including doctors of optometry, have long been impacted by stagnant Medicare reimbursement.

“The costs to deliver care continue to increase especially in regard to staffing and overhead costs, yet Medicare reimbursement has remained stagnant and proposed cuts only threaten to hamper physicians’ ability to provide valued care. S. 4935 takes a long-term, forward-looking approach to a real solution—not a patch—to address this problem.”

Medicare patients should be able to access quality health care, Sen. Boozman says.

“Ensuring physicians are fairly compensated for their work will help deliver stability to providers so they continue to meet the needs of their communities,” Sen. Boozman says. “I’m proud to lead this bipartisan solution that enhances Medicare’s sustainability.”

Stagnant Medicare reimbursements

In July, the Centers for Medicare & Medicaid Services released its proposed 2025 Medicare Physician Fee Schedule.

Unfortunately, CMS proposed a 2.8%-2.93% physician pay cut next year. The relative value unit (RVU) for services provided would fall from $33.29 to $32.36.

According to CMS, payments are “based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense and malpractice expense. These RVUs become payment rates through the application of a conversion factor.”

These latest cuts are part of a nearly two-decade decline in reimbursements, threatening access to health care for the elderly and disabled.

Permanent fix preferred by doctors

With yearly cuts in Medicare reimbursements and rising costs to provide quality health care, it becomes more important than ever for Congress to address the Medicare pay cuts and stabilize Medicare reimbursements now and in the future, says Deanna Alexander, O.D., chair of the AOA Federal Relations Committee.

“Providers need assurance that the Medicare system is not subject to continual cuts, which eventually contribute to a decrease in access to quality health care that our senior population deserves,” Dr. Alexander says. “Uncertainty comes from year after year of cuts and never knowing where the reimbursements are until the end of the year.”

Beyond the AOA, the Physician Fee Stabilization Act is supported by several health organizations including the American Medical Association, American Academy of Ophthalmology, American College of Surgeons, National Rural Health Association, American College of Radiology and American Gastroenterological Association.

CMS will be accepting comments on its 2025 proposals through Sept. 9 .

Take action

⏩  Urge Congress to take action. Go to the AOA Action Center and support S. 4935 / H.R. 2474.

How Chevron ruling could impact optometry

A recent Supreme Court ruling could call into question certain federal regulations. The AOA is seeking feedback on regulations that burden your practice.

Takeaways from CMS’ proposed 2025 Physician Fee Schedule

The Centers for Medicare & Medicaid Services released its proposed rule changes last week. The proposals recognize the value of vision care and the need for greater access to care for patients.

FTC issues 10-year Eyeglass Rule update as AOA renews demand for crackdown on medical device scammers

A nearly decade-long rule review ends with new requirements for prescribers, yet commissioners abandon two once-proposed, damaging policies after AOA insistence.

Forgot username  or  password ?

Not a Member?

Become a member  today to access this page..

You do not have access to this content. Call 314.983.4167 for assistance.

Not a member?  Join the AOA today !

An official website of the United States government

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

CMS Newsroom

Search cms.gov.

• Physician Fee Schedule
• Local Coverage Determination
• Medically Unlikely Edits

2024-08-08-MLNC

Thursday, August 8, 2024

Final Payment Rule

• Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System FY 2025 Final Rule

Transitional Coverage for Emerging Technologies — Final Notice

Help improve the program for evaluating payment patterns electronic reports & comparative billing reports — updated request for information, immunization: protect your patients.

• Medical Services Authorized by the Veterans Health Administration: Avoid Duplicate Payments

Claims, Pricers, & Codes

• Clinical Laboratory Improvement Amendments: Reprocessing Denied Claims

Skilled Nursing Facility Prospective Payment System: FY 2025 Pricer Update

Clinical diagnostic laboratory tests: medicare advisory panel meeting materials, from our federal partners, mpox caused by human-to-human transmission of monkeypox   virus in the democratic republic of the congo with spread to neighboring countries.

• Ready to Get Paid via EFT for CHAMPVA Claims?

Hospital Inpatient Prospective Payment System & Long-Term Care Hospital Prospective Payment System  FY 2025 Final Rule

Learn about the FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) final rule .

More Information:

• IPPS rule and related files
• LTCH PPS rule and related files
• Press release

News  

CMS is committed to making sure people with Medicare have access to medical advancements that improve health outcomes and enhance health quality.   CMS’ Transitional Coverage for Emerging Technologies (TCET) Pathway helps people with Medicare access the latest medical advances, enables doctors and other clinicians to provide the best care for their patients, and benefits manufacturers who create innovative technologies. With support from policymakers, trust from patients and providers, and meaningful collaboration with manufacturers, CMS aims to improve the care and quality of life for people with Medicare while enhancing and encouraging innovation.   

CMS issued a final procedural notice outlining a Medicare coverage pathway to achieve more timely and predictable access to certain new medical technologies for people with Medicare. The new TCET pathway for certain FDA-designated Breakthrough Devices increases the number of National Coverage Determinations (NCDs) that CMS will conduct per year and supports both improved patient care and innovation by providing a clear, transparent, and consistent coverage process while maintaining robust safeguards for the Medicare population. CMS anticipates accepting up to five TCET candidates per year and, for technologies accepted into and continuing in the TCET pathway, CMS’ goal is to finalize an NCD within six months after FDA market authorization.

See the full fact sheet for more information.  

CMS is taking steps to improve the effectiveness, accessibility, and design of the Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) and Comparative Billing Reports (CBRs). You can help by responding to questions in the updated  Request for Information by August 19, 2024.

See  Medicare Fee-for-Service Compliance Programs for more information.  

Fewer than 25% of adults get all their recommended vaccines, and  minority populations have even lower vaccination rates (See  CDC and  NIH ). During  National Immunization Awareness Month , help increase your patients’ vaccination rates by recommending vaccines and how to access them.

Medicare covers the following vaccines:

• Hepatitis B
• Pneumococcal

Your patients pay nothing if you accept assignment. Find out when your patient is  eligible for these vaccines . If you need help, contact your eligibility service provider.  

• Immunization and Vaccine Resources webpage
• Medicare Part D Vaccines (PDF) fact sheet
• CDC Adult Vaccination Resources webpage

For Your Patients:

• Vaccines.gov website
• COVID-19 vaccine
• Pneumococcal shots
• Hepatitis B shots  

Medical Services Authorized by the Veterans Health Administration: Avoid Duplicate Payments  

In a  report , the Office of the Inspector General found that Medicare paid providers for medical services authorized and paid for by the Department of Veterans Affairs’ community care programs, resulting in duplicate payments of up to $128 million. We don’t pay for services authorized under Veterans Health Administration benefits. 

More information to bill correctly:

• Medicare Secondary Payer (PDF) booklet
• Medicare Overpayments (PDF) fact sheet
• Section 50.1.1  Medicare Benefit Policy Manual, Chapter 16 (PDF)

Clinical Laboratory Improvement Amendments: Reprocessing Denied Claims  

CMS corrected a programming error that caused Part B laboratory service claims processed July 19–24 to deny. Your Medicare Administrative Contractor will reprocess affected claims within 30 days.  You don’t need to take any action.  

CMS published payment rates effective October 1, 2024, in the  FY 2025 Skilled Nursing Facility (SNF) final rule.   

Effective FY 2023, CMS won’t reduce SNF final wage indexes by more than 5% compared to the prior FY. This doesn’t apply to new SNFs that open in FY 2025 because they didn’t have a prior wage index. 

• Section 30.5  Medicare Claims Processing Manual, Chapter 6 (PDF)
• Instruction to your Medicare Administrative Contractor (PDF)

CMS posted meeting materials from the Medicare Advisory Panel on Clinical Diagnostic Laboratory Tests:

• Recording from July 25, 2024 - Passcode: v9P8rC%Y
• Recording from July 26, 2024 - Passcode: G?=W7EmY
• Panel voting results (ZIP)  

The CDC   issued this Health Alert Network Health Update to provide additional information about the outbreak of monkeypox virus (MPXV) in the Democratic Republic of the Congo (DRC); the first Health Advisory about this outbreak was released in December 2023.

No cases of clade I mpox have been reported outside central and eastern Africa at this time. Because there is a risk of additional spread, CDC recommends clinicians and jurisdictions in the U.S. maintain a heightened index of suspicion for mpox in patients who have recently been in DRC or to any country sharing a border with DRC (ROC, Angola, Zambia, Rwanda, Burundi, Uganda, South Sudan, CAR) and present with signs and symptoms consistent with mpox . These can include: rash that may be located on the hands, feet, chest, face, mouth, or near the genitals; fever; chills; swollen lymph nodes; fatigue; myalgia (muscle aches and backache); headache; and respiratory symptoms like sore throat, nasal congestion, and cough. 

See the full  Health Update for more information, including recommendations for clinicians on:

• Evaluation and diagnosis
• Treatment and prevention  

Ready to Get Paid via EFT for CHAMPVA Claims?  

If you see patients under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), you must enroll in direct deposit (electronic funds transfer (EFT)) to get your payments. It’s a  federal requirement .

2 steps to enroll in EFT:

• Visit the VA Financial Services Center  Customer Engagement Portal
• Review the  Vendor Webform User Guide for step-by-step instructions
• Call 877-353-9791 if you need help with the webform

The VA will automatically deposit payments into your bank account. If you aren’t enrolled in EFT, the VA will pause your payments. 

About CHAMPVA

CHAMPVA  is a health care program for qualified spouses, widows, and children. Through CHAMPVA, VA shares the cost of certain health care services and supplies with eligible beneficiaries. 

• CHAMPVA – Information for Providers  webpage
• U.S. Department of Veterans Affairs  webpage  

Subscribe to the MLN Connects® newsletter, or  read past editions .

View the  Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

How does Medicare work?

Generally, you only need to sign up for Part A and Part B once. Each year, you can choose which way you get your health coverage (and add or switch drug coverage).

Medicare is different from private insurance — it doesn’t offer plans for couples or families. You don’t have to make the same choice as your spouse.

2 steps to set up your Medicare coverage:

• Sign up for Part A (Hospital Insurance) and Part B (Medical Insurance) You can sign up at certain times. Check when and how to sign up.
• Choose which way you want to get your Medicare health coverage  You can choose either Original Medicare or Medicare Advantage (Part C) for your health coverage. If you choose Original Medicare, you’ll also decide if you want drug coverage (Part D) and supplemental coverage, like Medigap .

You’ll have Original Medicare unless you join a Medicare Advantage Plan.

How does Original Medicare work?

Original Medicare includes two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) . Original Medicare covers most, but not all of the costs for approved health care services and supplies. After you meet your deductible, you pay your share of costs for services and supplies as you get them. There’s no limit on what you’ll pay out-of-pocket in a year unless you have other coverage (like Medigap, Medicaid, or employee or union coverage). Get details on cost saving programs.

Services covered by Medicare must be medically necessary.  Medicare also covers many preventive services, like shots and screenings. If you go to a doctor or other health care provider that accepts the Medicare-approved amount , your share of costs may be less. If you get a service that Medicare doesn’t cover, you pay the full cost.

With Original Medicare, you can:

• Go to any doctor or hospital that takes Medicare, anywhere in the U.S. Find providers that work with Medicare.
• Join a separate Medicare drug plan (Part D) to get drug coverage.
• Buy a Medicare Supplement Insurance (Medigap) policy to help lower your share of costs for services you get.

If you have other insurance, learn how Original Medicare works with your other coverage.

If you're not lawfully present in the U.S., Medicare won't pay for your Part A and Part B claims, and you can't enroll in a Medicare Advantage Plan or a Medicare drug plan.

How does Medicare Advantage work?

Medicare Advantage bundles your Part A, Part B, and usually Part D coverage into one plan. Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

You join a plan offered by Medicare-approved private companies that follow rules set by Medicare. Each plan can have different rules for how you get services, like needing referrals to see a specialist. Costs for monthly premiums and services you get vary depending on which plan you join.

Plans must cover all emergency and urgent care, and almost all medically necessary services Original Medicare covers. Some plans tailor their benefit packages to offer additional benefits to treat specific conditions.

With Medicare Advantage, you:

• Need to use doctors who are in the plan’s network (for non-emergency or non-urgent care).
• May pay a premium for the plan in addition to the monthly Part B premium. Plans may have a $0 premium or may help pay all or part of your Part B premiums.
• Can’t buy separate supplemental coverage (like Medigap).

You must have both Part A and Part B to join a Medicare Advantage Plan.

How does Medicare work with my other insurance?

When you have Medicare and other health insurance (like from your job), one will pay first (called a “primary payer”) and the other second (called a “secondary payer”).

If you have other insurance, who pays first depends on a number of items, like if you’re still working, the type of insurance you have, and if you have a special situation, like End-Stage Renal Disease (ESRD).

Get details if you’re working past 65, or getting ready to retire.

Find out who pays first in your situation.

What do you want to do next?

Check when & how to sign up

Get answers for your situation

Estimate my eligibility

Get estimate of when you can first sign up

• Get My Sign-up Date

Compare benefits side-by-side

Compare Original Medicare & Medicare Advantage

• Compare Options

You're reading a free article with opinions that may differ from The Motley Fool's Premium Investing Services. Become a Motley Fool member today to get instant access to our top analyst recommendations, in-depth research, investing resources, and more. Learn More

3 Savvy Medicare Moves That Could Slash Your Healthcare Costs in Retirement

• Healthcare tends to be a large expense for retirees.
• A few strategic Medicare decisions could help you save a lot of money.
• Motley Fool Issues Rare “All In” Buy Alert

Worried about paying for medical expenses? Here's how to lower your Medicare costs and bank the difference.

There are certain expenses you might encounter in retirement that are optional, like paying for cable, and those that are non-negotiable, like paying for food. Healthcare falls into the latter category. And unfortunately, it can be more expensive than a lot of retirees bargain for.

Last year, Fidelity projected that the typical 65-year-old would be looking at a whopping $157,500 to cover their healthcare expenses throughout retirement. Reading between the lines, this tells us that people with pre-existing health issues might spend even more on their care. Given that the median retirement savings account balance among Americans aged 65 to 74 is only $200,000, per the Federal Reserve, that paints a pretty scary picture.

The good news, though, is that there are steps you can take to lower your healthcare spending as a retiree. But it all boils down to making smart Medicare moves like these.

Image source: Getty Images.

1. Avoid a Part B surcharge

Your initial Medicare enrollment window lasts seven months, beginning three months before the month of your 65th birthday and ending three months after that month. If you're covered by a qualified group health plan at the time of your initial enrollment period, you don't have to worry about being penalized for signing up for Medicare after this time period expires. But if that's not the case and you don't have qualifying group health coverage, you'll risk a costly penalty for life for a late enrollment.

Specifically, you'll be assessed a 10% surcharge on your Medicare Part B premium for each yearlong period when you were eligible to enroll but didn't. This surcharge won't apply to Part A, since enrollees generally don't pay a premium for that hospital coverage. However, a separate surcharge may apply to your Part D drug plan if you're late with your enrollment.

To avoid these extra costs, sign up on time unless you have group health coverage that entitles you to a special enrollment period later on. It's that simple.

2. Sign up for supplemental insurance as soon as you can

Medicare enrollees can choose between original Medicare and Medicare Advantage . If you select an Advantage plan, it will generally cover all of your health-related needs so that you don't have to shop around for a separate drug plan.

If you decide to stick with original Medicare -- which you may want to do since it generally gives you access to a much broader provider network -- be sure to sign up for supplemental insurance known as Medigap as soon as you're able to. Your initial Medigap signup window starts the first month you're enrolled in Part B and are 65 or older. That period lasts six months, so it's a bit shorter than your initial Medicare enrollment window.

Medigap won't pay for services that Medicare itself won't cover, like dental care. But it can pick up the tab for expenses like hospital deductibles and coinsurance, so it's important to explore your options during your initial enrollment window. Waiting longer puts you at risk of being denied coverage. And if you are approved, you might get stuck paying more.

3. Take advantage of Medicare's free preventive services

There are many services you might receive as a Medicare enrollee that you'll have to pay for to some degree, whether in the form of a deductible, coinsurance, or copay. But certain Medicare services are available to enrollees free of charge. It's important to take advantage of those preventive options to protect your health and potentially avoid costlier medical bills down the line.

Medicare enrollees, for example, generally get a free wellness visit each year. Scheduling yours could help a provider identify and treat a health issue before it escalates into a more serious and expensive problem.

Paying a fair amount for healthcare may be unavoidable once you retire. But these Medicare moves could make an otherwise giant expense a lot more manageable.

The Motley Fool has a disclosure policy .

Related Articles

Premium Investing Services

Invest better with The Motley Fool. Get stock recommendations, portfolio guidance, and more from The Motley Fool's premium services.