Q: What does it mean if your doctor doesn’t accept assignment?
A: If your doctor doesn’t “accept assignment,” (ie, is a non-participating provider) it means he or she might see Medicare patients and accept Medicare reimbursement as partial payment, but wants to be paid more than the amount that Medicare is willing to pay.
As a result, you may end up paying the difference between what Medicare will pay and what your provider charges—up to 15 percent above the amount that participating providers are paid by Medicare, in addition to your normal deductible and coinsurance. (This additional 15 percent is known as a limiting charge; states can impose a lower threshold, but it cannot exceed 15 percent.)
If your doctor doesn’t accept assignment, you may have to pay the entire bill upfront and seek reimbursement for the portion that Medicare will pay. If you have to seek reimbursement from Medicare, you’ll use Form CMS 1490-S.
Participating Medicare providers are those who have agreed to accept Medicare’s negotiated payments as payment in full for all Medicare services (this includes the patient’s deductible and coinsurance, as well as the portion that Medicare pays). In other words, they accept assignment for all services.
Non-participating providers don’t have to accept assignment for all Medicare services, but they may accept assignment for some individual services. If they accept assignment for a particular service, they can’t bill the patient for any additional amounts beyond the regular Medicare deductible and coinsurance, for that specific treatment.
Providers can go a step beyond non-participation, by opting out of Medicare altogether—although only a very small fraction of provider take this option. In that case, they have no contract at all with Medicare, leaving patients with potential exposure to higher out-of-pocket costs. If a Medicare enrollee sees a doctor who has opted out of Medicare, the patient is responsible for the full bill—the provider cannot bill Medicare, and Medicare will not reimburse the patient for any of the charges. Providers who have opted out of Medicare have to disclose this information to patients with Medicare.
Medicare publishes monthly reports showing which providers have opted out. The out-out period lasts for two years—after that, a provider can opt back in or can continue to opt-out; CMS currently uses an automatic renewal provision, so providers who have opted out can continue that approach without contacting CMS every two years. The number of providers who opted out of Medicare climbed sharply from 2012 through 2016, but dropped by about half in 2017.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.