Does your provider accept Medicare as full payment?

You can get the lowest cost if your doctor or other health care provider accepts the Medicare-approved amount  as full payment for a covered service. This is called “accepting assignment.” If a provider accepts assignment, it’s for all Medicare-covered Part A and Part B services.

Using a provider that accepts assignment

Most doctors, providers, and suppliers accept assignment, but always check to make sure that yours do.

If your doctor, provider, or supplier accepts assignment:

  • Your out-of-pocket costs may be less.
  • They agree to charge you only the Medicare deductible and coinsurance amount, and usually wait for Medicare to pay its share before asking you to pay your share.
  • They have to submit your claim directly to Medicare and can't charge you for submitting the claim.

How does assignment impact my drug coverage?

Using a provider that doesn't accept Medicare as full payment

Some providers who don’t accept assignment still choose to accept the Medicare-approved amount for services on a case-by-case basis. These providers are called "non-participating."

If your doctor, provider, or supplier doesn't accept assignment:

  • You might have to pay the full amount at the time of service.
  • They should submit a claim to Medicare for any Medicare-covered services they give you, and they can’t charge you for submitting a claim. If they refuse to submit a Medicare claim, you can submit your own claim to Medicare. Get the Medicare claim form .
  • They can charge up to 15% over the Medicare-approved amount for a service, but no more than that. This is called "the limiting charge."  

Does the limiting charge apply to all Medicare-covered services?

Using a provider that "opts-out" of Medicare

  • Doctors and other providers who don’t want to work with the Medicare program may "opt out" of Medicare.
  • Medicare won’t pay for items or services you get from provider that opts out, except in emergencies.
  • Providers opt out for a minimum of 2 years. Every 2 years, the provider can choose to keep their opt-out status, accept Medicare-approved amounts on a case-by-case basis ("non-participating"), or accept assignment.

Find providers that opted out of Medicare.

Private contracts with doctors or providers who opt out

  • If you choose to get services from an opt-out doctor or provider you may need to pay upfront, or set up a payment plan with the provider through a private contract.
  • Medicare won’t pay for any service you get from this doctor, even if it’s a Medicare-covered service.

What are the rules for private contracts?

You may want to contact your  State Health Insurance Assistance Program (SHIP) for help before signing a private contract with any doctor or other health care provider.

What do you want to do next?

  • Next step: Get help with costs
  • Take action: Find a provider
  • Get details: How to get Medicare services

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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.

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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.

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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.

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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.

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Medicare Assignment: Everything You Need to Know

Medicare assignment.

  • Providers Accepting Assignment
  • Providers Who Do Not
  • Billing Options
  • Assignment of Benefits
  • How to Choose

Frequently Asked Questions

Medicare assignment is an agreement between Medicare and medical providers (doctors, hospitals, medical equipment suppliers, etc.) in which the provider agrees to accept Medicare’s fee schedule as payment in full when Medicare patients are treated.

This article will explain how Medicare assignment works, and what you need to know in order to ensure that you won’t receive unexpected bills.

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There are 35 million Americans who have Original Medicare. Medicare is a federal program and most medical providers throughout the country accept assignment with Medicare. As a result, these enrollees have a lot more options for medical providers than most of the rest of the population.

They can see any provider who accepts assignment, anywhere in the country. They can be assured that they will only have to pay their expected Medicare cost-sharing (deductible and coinsurance, some or all of which may be paid by a Medigap plan , Medicaid, or supplemental coverage provided by an employer or former employer).

It’s important to note here that the rules are different for the 29 million Americans who have Medicare Advantage plans. These beneficiaries cannot simply use any medical provider who accepts Medicare assignment.

Instead, each Medicare Advantage plan has its own network of providers —much like the health insurance plans that many Americans are accustomed to obtaining from employers or purchasing in the exchange/marketplace .

A provider who accepts assignment with Medicare may or may not be in-network with some or all of the Medicare Advantage plans that offer coverage in a given area. Some Medicare Advantage plans— health maintenance organizations (HMOs) , in particular—will only cover an enrollee’s claims if they use providers who are in the plan's network.

Other Medicare Advantage plans— preferred provider organizations (PPOs) , in particular—will cover out-of-network care but the enrollee will pay more than they would have paid had they seen an in-network provider.

Original Medicare

The bottom line is that Medicare assignment only determines provider accessibility and costs for people who have Original Medicare. People with Medicare Advantage need to understand their own plan’s provider network and coverage rules.

When discussing Medicare assignment and access to providers in this article, keep in mind that it is referring to people who have Original Medicare.

How to Make Sure Your Provider Accepts Assignment

Most doctors, hospitals, and other medical providers in the United States do accept Medicare assignment.

Provider Participation Stats

According to the Centers for Medicare and Medicaid Services, 98% of providers participate in Medicare, which means they accept assignment.

You can ask the provider directly about their participation with Medicare. But Medicare also has a tool that you can use to find participating doctors, hospitals, home health care services, and other providers.

There’s a filter on that tool labeled “Medicare-approved payment.” If you turn on that filter, you will only see providers who accept Medicare assignment. Under each provider’s information, it will say “Charges the Medicare-approved amount (so you pay less out-of-pocket).”

What If Your Provider Doesn’t Accept Assignment?

If your medical provider or equipment supplier doesn’t accept assignment, it means they haven’t agreed to accept Medicare’s approved amounts as payment in full for all of the services.

These providers can still choose to accept assignment on a case-by-case basis. But because they haven’t agreed to accept Medicare assignment for all services, they are considered nonparticipating providers.

Note that "nonparticipating" does not mean that a provider has opted out of Medicare altogether. Medicare will still pay claims for services received from a nonparticipating provider (i.e., one who does not accept Medicare assignment), whereas Medicare does not cover any of the cost of services obtained from a provider who has officially opted out of Medicare.

If a Medicare beneficiary uses a provider who has opted out of Medicare, that person will pay the provider directly and Medicare will not be involved in any way.

Physicians Who Have Opted Out

Only about 1% of all non-pediatric physicians have opted out of Medicare.

For providers who have not opted out of Medicare but who also don’t accept assignment, Medicare will still pay nearly as much as it would have paid if you had used a provider who accepts assignment. Here’s how it works:

  • Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment.
  • The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as the limiting charge . But the 15% cap does not apply to medical equipment suppliers; if they do not accept assignment with Medicare, there is no limit on how much they can charge the person receiving care. This is why it’s particularly important to make sure that the supplier accepts Medicare assignment if you need medical equipment.
  • The nonparticipating provider may require the person receiving care to pay the entire bill up front and seek reimbursement from Medicare (using Form CMS 1490-S ). Alternatively, they may submit a claim to Medicare on behalf of the person receiving care (using Form CMS-1500 ).
  • A nonparticipating provider can choose to accept assignment on a case-by-case basis. They can indicate this on Form CMS-1500 in box 27. The vast majority of nonparticipating providers who bill Medicare choose to accept assignment for the claim being billed.
  • Nonparticipating providers do not have to bill your Medigap plan on your behalf.

Billing Options for Providers Who Accept Medicare

When a medical provider accepts assignment with Medicare, part of the agreement is that they will submit bills to Medicare on behalf of the person receiving care. So if you only see providers who accept assignment, you will never need to submit your own bills to Medicare for reimbursement.

If you have a Medigap plan that supplements your Original Medicare coverage, you should present the Medigap coverage information to the provider at the time of service. Medicare will forward the claim information to your Medigap insurer, reducing administrative work on your part.

Depending on the Medigap plan you have, the services that you receive, and the amount you’ve already spent in out-of-pocket costs, the Medigap plan may pay some or all of the out-of-pocket costs that you would otherwise have after Medicare pays its share.

(Note that if you have a type of Medigap plan called Medicare SELECT, you will have to stay within the plan’s network of providers in order to receive benefits. But this is not the case with other Medigap plans.)

After the claim is processed, you’ll be able to see details in your MyMedicare.gov account . Medicare will also send you a Medicare Summary Notice. This is Medicare’s version of an explanation of benefits (EOB) , which is sent out every three months.

If you have a Medigap plan, it should also send you an EOB or something similar, explaining the claim and whether the policy paid any part of it.

What Is Medicare Assignment of Benefits?

For Medicare beneficiaries, assignment of benefits means that the person receiving care agrees to allow a nonparticipating provider to bill Medicare directly (as opposed to having the person receiving care pay the bill up front and seek reimbursement from Medicare). Assignment of benefits is authorized by the person receiving care in Box 13 of Form CMS-1500 .

If the person receiving care refuses to assign benefits, Medicare can only reimburse the person receiving care instead of paying the nonparticipating provider directly.

Things to Consider Before Choosing a Provider

If you’re enrolled in Original Medicare, you have a wide range of options in terms of the providers you can use—far more than most other Americans. In most cases, your preferred doctor and other medical providers will accept assignment with Medicare, keeping your out-of-pocket costs lower than they would otherwise be, and reducing administrative hassle.

There may be circumstances, however, when the best option is a nonparticipating provider or even a provider who has opted out of Medicare altogether. If you choose one of these options, be sure you discuss the details with the provider before proceeding with the treatment.

You’ll want to understand how much is going to be billed and whether the provider will bill Medicare on your behalf if you agree to assign benefits (note that this is not possible if the provider has opted out of Medicare).

If you have supplemental coverage, you’ll also want to check with that plan to see whether it will still pick up some of the cost and, if so, how much you should expect to pay out of your own pocket.

A medical provider who accepts Medicare assignment is considered a participating provider. These providers have agreed to accept Medicare’s fee schedule as payment in full for services they provide to Medicare beneficiaries. Most doctors, hospitals, and other medical providers do accept Medicare assignment.

Nonparticipating providers are those who have not signed an agreement with Medicare to accept Medicare’s rates as payment in full. However, they can agree to accept assignment on a case-by-case basis, as long as they haven’t opted out of Medicare altogether. If they do not accept assignment, they can bill the patient up to 15% more than the Medicare-approved rate.

Providers who opt out of Medicare cannot bill Medicare and Medicare will not pay them or reimburse beneficiaries for their services. But there is no limit on how much they can bill for their services.

A Word From Verywell

It’s in your best interest to choose a provider who accepts Medicare assignment. This will keep your costs as low as possible, streamline the billing and claims process, and ensure that your Medigap plan picks up its share of the costs.

If you feel like you need help navigating the provider options or seeking care from a provider who doesn’t accept assignment, the Medicare State Health Insurance Assistance Program (SHIP) in your state may be able to help.

A doctor who does not accept Medicare assignment has not agreed to accept Medicare’s fee schedule as payment in full for their services. These doctors are considered nonparticipating with Medicare and can bill Medicare beneficiaries up to 15% more than the Medicare-approved amount.

They also have the option to accept assignment (i.e., accept Medicare’s rate as payment in full) on a case-by-case basis.

There are certain circumstances in which a provider is required by law to accept assignment. This includes situations in which the person receiving care has both Medicare and Medicaid. And it also applies to certain medical services, including lab tests, ambulance services, and drugs that are covered under Medicare Part B (as opposed to Part D).

In 2021, 98% of American physicians had participation agreements with Medicare, leaving only about 2% who did not accept assignment (either as a nonparticipating provider, or a provider who had opted out of Medicare altogether).

Accepting assignment is something that the medical provider does, whereas assignment of benefits is something that the patient (the Medicare beneficiary) does. To accept assignment means that the medical provider has agreed to accept Medicare’s approved fee as payment in full for services they provide.

Assignment of benefits means that the person receiving care agrees to allow a medical provider to bill Medicare directly, as opposed to having the person receiving care pay the provider and then seek reimbursement from Medicare.

Centers for Medicare and Medicaid Services. Medicare monthly enrollment .

Centers for Medicare and Medicaid Services. Annual Medicare participation announcement .

Centers for Medicare and Medicaid Services. Lower costs with assignment .

Centers for Medicare and Medicaid Services. Find providers who have opted out of Medicare .

Kaiser Family Foundation. How many physicians have opted-out of the Medicare program ?

Center for Medicare Advocacy. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) updates .

Centers for Medicare and Medicaid Services. Check the status of a claim .

Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 26 - completing and processing form CMS-1500 data set .

Centers for Medicare and Medicaid Services. Ambulance fee schedule .

Centers for Medicare and Medicaid Services. Prescription drugs (outpatient) .

By Louise Norris Louise Norris has been a licensed health insurance agent since 2003 after graduating magna cum laude from Colorado State with a BS in psychology.

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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 .

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Everything PTs Need to Know About Accepting Medicare Assignment

There's no one-size fits all answer as to whether or not a PT should accept Medicare assignment, but you can better understand your options.

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Over the years, we’ve written quite a few blog posts about Medicare—covering everything from Medicare and direct access to Medicare supervision requirements —and I don’t foresee that stopping any time soon. After all, there are so many intricacies and nuances to navigating Medicare that we have fodder to write until, well, either the end of time or the end of Medicare—whichever comes first. Today, let’s review one of the most fundamental Medicare concepts: the notion of accepting assignment. Here, we’ll help clarify what that means for physical therapists—and the pros and cons of doing so.

What does it mean to accept Medicare assignment?

In short, accepting Medicare assignment means signing a contract to accept whatever Medicare pays for a covered service as full payment. 

Participating Providers

Providers who accept Medicare assignment for all covered services are considered participating providers under Medicare and may not charge patients above and beyond what Medicare agrees to pay. These providers may, however, collect patient deductibles and coinsurances—although, as explained on this page , these providers typically ask Medicare to pay its share before collecting anything from the patient. Per the same resource, these providers are required to submit claims directly to Medicare for reimbursement and cannot charge patients for the claim submission. As Dr. Jarod Carter, PT, DPT, MTC, writes in this blog post , “This is the most common and best-understood relationship that physical therapists have with Medicare.”

Because Medicare beneficiaries often pay less out of pocket when receiving care from a provider who accepts assignment, patients may be more willing to work with these providers. Thus, if you accept assignment, you may have access to not only more Medicare patients, but also more potential referral partners who only work with assignment-accepting providers. 

You must accept whatever Medicare deems appropriate compensation, and as we know, that’s below market value more often than not. Given the recently announced cuts to assistant-provided services and the 8% cut to all physical therapy services , accepting assignment may be increasingly less appealing to physical therapists. That said, if you serve a large Medicare population, the volume of patients you see may make it financially beneficial for you to continue playing by Medicare’s rules.

If you don’t want to accept Medicare assignment, what are your other options?

Non-participating providers.

As Meredith Castin explains in this blog post , Medicare also allows physical therapists to be non-participating providers (a.k.a. non-enrolled providers), which simply means that, while they are still in a contractual relationship with Medicare (and thus, are eligible to provide covered services to Medicare beneficiaries), they have not agreed to accept assignment across the board. As such, these providers may charge more than what Medicare pays for a particular service up to a limit that Medicare calls “the limiting charge.” Non-participating providers may choose to accept assignment for some services, but not others —or no services at all. For services that are not under assignment, the provider may collect payment directly from the patient; however, he or she must still bill Medicare, so that Medicare may reimburse the patient.

Non-participating providers are still eligible to serve Medicare beneficiaries, but they maintain some degree of freedom when it comes to pricing their services. In other words, if you are a non-participating provider, you are less beholden to what Medicare deems as appropriate payment than you are as a participating provider.

That said, you do still have to charge within Medicare’s limit, which means your freedom is far from total. Additionally, because patients may have to pay more out of pocket for your services and/or pay and wait for reimbursement from Medicare, you may have to work harder to convince them that you’re worth the financial investment. With the right data and marketing , it’s definitely doable; it may just require a little more effort.

No Relationship with Medicare

Physicians are eligible to “opt out” of Medicare, which means that even if they are neither participating nor nonparticipating providers, they can still see Medicare beneficiaries on a cash-pay basis. Physical therapists do not enjoy the same privilege. So, if you decide not to be a Medicare participating provider or non-participating provider, then you effectively have no relationship with Medicare. Thus, you are not able to provide Medicare-covered services to Medicare beneficiaries. 

That said, all physical therapists, regardless of their relationship with Medicare, may provide never-covered services to Medicare beneficiaries, including wellness services. According to Castin, though, providers who go down that route, “need to be very clear about Medicare’s definition of ‘wellness services’ versus ‘physical therapy services.’” According to cash-pay PT Jarod Carter , it’s imperative for your documentation to clearly support that the services were indeed wellness as opposed to therapy. 

As a provider with no relationship with Medicare, you’re not required to play by Medicare’s rules when it comes to reporting requirements or (low-ball) payments. You’re also not at all affected by Medicare’s most recent cuts, which, quite frankly, is a big bonus.

However, as of 2007 , 15% of the US population was enrolled in Medicare; that’s 44 million people—most of whom could benefit from seeing a physical therapist to improve function and mobility and decrease pain. And that number is projected to grow to 79 million people by 2030. As such, choosing not to play ball with Medicare means you’re walking away from a very large market of patients who need your services. 

Deciding whether or not to accept Medicare assignment—and what type of relationship you’d like to have with Medicare—is not an easy decision to make, and there are a lot of factors to take into consideration before getting involved or breaking it off with this substantial federal payer. That said, it is important to know that you have options. Have more questions about what it means to accept assignment as a PT? Ask them below, and we’ll do our best to find you an answer.

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What Is Medicare?

Can doctors refuse medicare.

  • 1. Stay Put and Pay the Difference
  • 2. Request a Discount
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  • 4. Ask for a Referral
  • 5. Search Medicare's Directory

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What to Do When Your Doctor Doesn't Take Medicare

Five options if you have Medicare but your doctor doesn't accept it

medicare not accepting assignment

Pete Rathburn is a copy editor and fact-checker with expertise in economics and personal finance and over twenty years of experience in the classroom.

medicare not accepting assignment

Not all doctors accept Medicare for the patients they see, an increasingly common occurrence. This can leave you with higher out-of-pocket costs than you anticipated and a tough decision if you really like that doctor.

So what happens when you sign up for Medicare only to learn it's a no-go at your favorite doctor? Fortunately, you have some options.

Key Takeaways

  • If you choose a doctor who accepts Medicare, you won't be charged more than the Medicare-approved amount for covered services .
  • A doctor can be a Medicare-enrolled provider, a non-participating provider, or an opt-out provider.
  • Your doctor's Medicare status determines how much Medicare covers and your options for finding lower costs.

Medicare is a federal government–sponsored program that provides health insurance for American citizens ages 65 and over. President Lyndon B. Johnson signed Medicare into law on July 30, 1965. By 1966, 19 million Americans were enrolled in the program.

Now, more than 50 years later, that number has mushroomed to over 60 million—more than 18% of the U.S. population. As more baby boomers reach age 65, enrollment is expected to hit 81 million in 2035. It’s no wonder that Medicare benefit payments totaled an estimated $744 billion in 2022.

Annual open enrollment for Medicare runs from Oct. 15 to Dec. 7 every year.

If your long-time physician accepts assignment, this means they agree to accept Medicare-approved amounts for medical services.

The short answer is "yes." Thanks to the federal program's low reimbursement rates, stringent rules, and grueling paperwork process, many doctors are refusing to accept Medicare's payment for services.

Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that Medicare reimbursements haven't kept pace with inflation in the past several years, especially the rising costs of running a medical practice. At the same time, the rules and regulations keep getting more onerous, as do penalties for not complying with them. 

Most American physicians participate in Medicare and "accept assignment" (what Medicare pays) for their services without additional charges. However, if your doctor is non-participating or has opted out of Medicare, here are five options.

Investopedia / Jake Shi

1. Stay Put and Pay the Difference

If your doctor is what's called a non-participating provider, it means they haven't signed an agreement to accept assignment for all Medicare-covered services, but can still choose to accept assignment for individual patients. In other words, your doctor may take Medicare patients but disagrees with the program's reimbursement rates. These non-participating providers can charge up to 15% over the official Medicare reimbursement amount.

If you choose to stick with your non-participating doctor, you'll have to pay the difference between the fees and the Medicare reimbursement. Plus, you may have to cough up the entire amount of the bill during your office visit. If you want to be paid back afterward, either your doctor will submit a claim to Medicare, or you may have to submit it yourself using Form CMS-1490S.

Let's say, for example, your doctor's bill comes to $300, and Medicare pays $250. This means you'll have to pay the $50 difference, plus any copay, out of pocket, assuming your doctor agrees to the program's reimbursement rates. This can add up quickly over time. However, you may be able to cover these extra expenses through a Medigap insurance policy , aka Medicare Supplement Insurance . Provided by private insurers, it is designed to cover expenses not covered by Medicare.

2. Request a Discount

If your doctor is what's called an opt-out provider, they may still be willing to see Medicare patients but will expect to be paid their full fee—not the smaller Medicare reimbursement amount. These docs accept no Medicare reimbursement, and Medicare doesn't pay for any portion of the bills you receive from them. That means you are responsible for paying the total bill out of pocket.

Opt-out physicians are required to reveal the cost of all their services to you upfront. These doctors will also have you sign a private contract saying you agree to the opt-out arrangement.

Of course, you can always try to negotiate a discount. It's not uncommon for physicians to lower their rates for established patients. As a courtesy, they may also offer extended payment plans if you require a series of expensive treatments or procedures.

3. Visit an Urgent Care Center

Urgent care centers have become a popular place for people to go for their healthcare needs. There are now more than 10,000 urgent care centers in the U.S. These centers may also operate as walk-in clinics. Many provide both emergency and non-emergency services, including the treatment of non-life-threatening injuries and illnesses, as well as lab services.

Most urgent care centers and walk-in clinics accept Medicare. Many of these clinics serve as primary care practices for some patients. If you need a flu shot or you've come down with a relatively minor illness, you may consider going to one of these clinics and save the doctor visits for the big stuff.

4. Ask Your Doctor for a Referral

If you simply cannot afford to stick with your doctor, ask them to recommend the next best doctor in town who does accept Medicare. Your current doctor has probably already prepared for this eventuality and arranged to transfer Medicare patients to another physician's care.

Just because you are eligible for Medicare doesn't mean you have to enroll in all four parts . If you have other health insurance—for example, you're still working and can remain covered by your employer's group plan—you may want to stick with that plan. Medicare Advantage Plan networks are another alternative to investigate. Physicians in those HMO -like plans have agreed to accept the network's fees.

5. Search Medicare's Directory

There are still plenty of doctors who take Medicare. You can find them in Medicare’s Physician Compare directory , a comprehensive list of physicians and healthcare providers across the nation. Once you pinpoint a provider, call to make sure they’re still taking on new Medicare patients. After all, this can change on a dime.

Another approach is to check the best local hospitals and see if any physicians on their staff are taking Medicare patients. When you get names, research them online to learn about their backgrounds.

On March 27, 2020, President Trump signed a  $2 trillion coronavirus emergency stimulus package , called the CARES (Coronavirus Aid, Relief, and Economic Security) Act, into law.  It expanded Medicare's ability to cover treatment and services for those affected by COVID-19. Parts of the CARES Act where extended including Increased flexibility for Medicare to cover telehealth services.

For Medicaid , the CARES Act clarifies that non-expansion states can use the Medicaid program to cover COVID-19–related services for uninsured adults who would have qualified for Medicaid if the state had chosen to expand. Other populations with limited Medicaid coverage are also eligible for coverage under this state option.

Does Every Doctor Accept Medicare?

No. Because of a number of factors, like lower reimbursement rates, paperwork, and regulations, some doctors choose to opt out of Medicare.

What Do I Do If My Doctor Does Not Accept Medicare?

You can choose to stay and cover the costs out-of-pocket, but this is not an affordable option for most Americans. Instead, you can ask your doctor for a referral to another healthcare provider that does accept Medicare, do your own research, or visit an urgent care facility. Most urgent care offices accept Medicare.

Why Do Doctors Refuse to Take Medicare?

Medicare is not always cost effective for doctors. It typically pays doctors only 80% of what private health insurance pays.

Thanks to plummeting reimbursement rates, ever-tightening rules, and cumbersome paperwork, many doctors are dropping Medicare. If you recently enrolled in Medicare only to find that your long-standing doctor doesn’t accept it, you have a number of options.

Whether you choose to stick with your cherished physician and pay the potentially exorbitant price or switch to a doctor who does accept Medicare, it’s important to carefully crunch the numbers before you make a final decision. Also, review your own medical situation and whether you need your current doctor—or someone with similar expertise—because of a specialized health issue.

Centers for Medicare and Medicaid Services. " History ."

Centers for Medicare and Medicaid Services. " Medicare: 35 Years of Service. " Download "Article Link (PDF)". Page 78.

Centers for Medicare and Medicaid Services. “ Trustees Report & Trust Funds .”

Centers for Medicare and Medicaid Services. " 2021 Medicare Trustees Report ," Page 193.

KFF. " The Facts About Medicare Spending ."

Medicare.gov. " Joining a Health or Drug Plan. "

Center for Medicare Advocacy. " Part B ."

Bulletin of the American College of Surgeons. " Medicare Physician Payment on the Decline: It's Not Your Imagination ."

Medicare FAQ. " What Is Medicare Assignment & What Doctors Accept It ."

Medicare.gov. “ Lower Costs With Assignment .”

Centers for Medicare and Medicaid Services. " CMS 1490S ."

Medicare. " What's Medicare Supplement Insurance (Medigap)? "

Medicare. " Opt Out Affidavits ."

Definitive Healthcare. " How many urgent care centers are in each U.S. state ?"

Medicare. " Medicare Advantage Plans ."

Department of the Treasury. " The CARES Act Works for All Americans ."

United States Department of Health and Human Services. " HHS Fact Sheet: Telehealth Flexibilities and Resources ."

Centers for Medicare and Medicaid Services. " Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic ."

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What is Medicare Assignment?

Written by: Rachael Zimlich, RN, BSN

Reviewed by: Eboni Onayo, Licensed Insurance Agent

Key Takeaways

Medicare assignment describes the fee structure that your doctor and Medicare have agreed to use.

If your doctor agrees to accept Medicare assignment, they agree to be paid whatever amount Medicare has approved for a service.

You may still see doctors who don’t accept Medicare assignment, but you may have to pay for your visit up front and submit a claim to Medicare for reimbursement.

You may have to pay more to see doctors who don’t accept Medicare assignment.

How Does Medicare Assignment Work?

What is Medicare assignment ?

Medicare assignment simply means that your provider has agreed to stick to a Medicare fee schedule when it comes to what they charge for tests and services. Medicare regularly updates fee schedules, setting specific limits for what it will cover for things like office visits and lab testing.

When a provider agrees to accept Medicare assignment, they cannot charge more than the Medicare-approved amount. For you, this means your out-of-pocket costs may be lower than if you saw a provider who did not accept Medicare assignment. The provider acknowledges that the amount Medicare set for a particular service is the maximum amount that will be paid.

You may still have to pay a Medicare deductible and coinsurance, but your provider will have to submit a claim to Medicare directly and wait for payment before passing any share of the costs onto you. Doctors who accept Medicare assignment cannot charge you to submit these claims.

Looking for dental, vision and hearing coverage?

How do I know if a Provider Accepts Medicare Assignments?

There are a few levels of commitment when it comes to Medicare assignment.

  • Providers who have agreed to accept Medicare assignment sign a contract with Medicare.
  • Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers.
  • Some providers opt out of Medicare altogether. Doctors who have opted out of Medicare completely or who use private contracts will not be paid anything by Medicare, even if it’s for a covered service within the fee limits. You will have to pay the full cost of any services provided by these doctors yourself.

How do I find a Medicare doctor? You can check to see if your provider accepts Medicare assignment on Medicare’s website .

Billing arrangement options for providers who accept Medicare

Doctors that take Medicare can sign a contract to accept assignment for all Medicare services, or be a non-participating provider that accepts assignment for some services but not all.

A medical provider that accepts Medicare assignment must submit claims directly to Medicare on your behalf. They will be paid the agreed upon amount by Medicare, and you will pay any copayments or deductibles dictated by your plan.

If your doctor is non-participating, they may accept Medicare assignment for some services but not others. Even if they do agree to accept Medicare’s fee for some services, Medicare will only pay then 95% of the set assignment cost for a particular service.

If your provider does plan to work with Medicare, either the provider or you can submit a claim to Medicare, but you may have to pay the entire cost of the visit up front and wait for reimbursement. They can’t charge you for more than the amount approved by Medicare, but they can charge you above the Medicare-approved amount. This is called the limiting charge, and can be up to 15% more than Medicare-approved amount for non-participating providers.

What Does it Mean when a Provider Does Not Accept Medicare Assignment?

Providers who refuse Medicare assignment can still choose to accept Medicare’s set fees for certain services. These are called non-participating providers.

There are a number of providers who opt out of participating in Medicare altogether; they are referred to as “opt-out doctors”. This means they have signed an opt-out agreement with Medicare and can’t be paid by Medicare at all — even for services normally covered by Medicare. Opt-out contracts last for at least two years. Some of these providers may only offer services to patients who sign contracts.

You do not need to sign a contract with a private provider or use an opt-out provider. There are many options for alternative providers who accept Medicare. If you do choose an opt-out or private contract provider, you will have to pay the full cost of services on your own.

What Medicare coverage is right for my specific situation?

Do providers have to accept Medicare assignment?

No. Providers can choose to accept a full Medicare assignment, or accept assignment rates for some services as a non-participating provider. Doctors can also opt out of participating in Medicare altogether.

How much will I have to pay if my provider doesn't accept Medicare assignment?

Some providers that don’t accept assignment as a whole will accept assignment for some services. These are called non-participating providers. For these providers and providers who have completely opted out of Medicare, you will pay the majority of or the full amount for your care.

How do I submit a claim?

If you need to submit your own claim to Medicare, you can call 1-800-MEDICARE or use Form CMS-1490S .

Can my provider charge to submit a claim?

No. Providers are not allowed to charge to submit a claim to Medicare on your behalf.

Lower Costs with Assignment. Medicare.gov.

Fee Schedules. CMS.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.

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Medicare Assignment: Understanding How It Works

Medicare Assignment

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.

what is medicare assignment

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.

what is an excess charge

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.

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How Many Physicians Have Opted Out of the Medicare Program?

Nancy Ochieng and Gabrielle Clerveau Published: Sep 11, 2023

Medicare provides health insurance coverage to 65 million adults– nearly 20% of the U.S population —and is a major source of revenue for providers, including physicians and other clinicians. In 2022, Medicare spending on Part B services (including physician services, outpatient services, and physician-administered drugs) accounted for nearly half (48%) of total Medicare benefit spending, and this share is expected to grow to more than half (52%) by 2032. Physicians are not required to participate in Medicare, though the vast majority of them choose to do so.

Every year, the Centers for Medicare and Medicaid Services (CMS) updates Medicare payments to physicians under the physician fee schedule through rulemaking, as required under law. Over the years, some have raised concerns that physicians would opt out of Medicare because Medicare payments for physician services are lower, on average, than payments from private insurers , potentially leading to a shortage of physicians willing to treat people with Medicare.

This brief builds on previous KFF analyses by providing the most recent data on the extent to which non-pediatric physicians are opting out of Medicare, by specialty and by state, in 2023, based on data published by CMS as of June 2023. ( See Methods box for details ).

Highlights:

  • One percent of all non-pediatric physicians have formally opted-out of the Medicare program in 2023, with the share varying somewhat by specialty type, and highest for psychiatrists (7.7%).
  • Psychiatrists account for the largest share (40.2%) of all non-pediatric physicians who have opted out of Medicare in 2023.
  • Less than two percent of physicians have opted-out of Medicare in all but four states and the District of Columbia, where the rate is slightly higher: Alaska (3.1%), Colorado (2.3%), Wyoming (2.3%), Idaho (2.1%), and the District of Columbia (2.0%).

Three options for physicians

Currently, physicians and other practitioners choosing to treat patients with Medicare and receive payments from Medicare for these services must enroll in Medicare as a Medicare provider. Physicians may either agree to be a participating provider or non-participating provider. Providers who do not want to enroll in Medicare, treat patients with Medicare, or receive Medicare payments are required to sign an “opt out” agreement with their patients.

  • Participating providers agree to accept “assignment” on all Medicare claims for alltheir Medicare patients, which means that they have signed a participation agreement with Medicare, agreeing to accept Medicare’s fee schedule amounts as payment-in-full for all Medicare covered services. Medicare beneficiaries seeing a participating provider can only be liable for the cost sharing required by Medicare. Providers have  several incentives  to be participating providers, such as being paid higher rates (5% higher) than the rates paid to non-participating providers. The  vast majority  (98%) of physicians and practitioners billing Medicare are participating providers.
  • Non-participating providers accept Medicare patients, but can choose whether to take assignment (i.e., Medicare’s approved amount) on a claim-by-claim basis. Unlike participating providers, who are paid the full Medicare-allowed payment amount, non-participating physicians who take assignment are limited to 95% of the Medicare approved amount. In 2021,  7% of fee schedule claims  by non-participating providers were paid on assignment. Physicians who choose to not accept assignment can charge beneficiaries more than the Medicare-approved amount, (“balance bill”) but not exceeding 15% of the fee-schedule allowed amount. Medicare patients are financially liable for this additional amount plus applicable deductibles and coinsurance amounts.
  • Opt-out physicians and other practitioners must sign an affidavit to “opt-out” of the Medicare program entirely. These providers enter into private contracts with their Medicare patients, allowing them to bill any amount they determine is appropriate. Providers who have opted-out of the Medicare program must opt-out for  all  of their Medicare patients. Medicare patients seeing a provider who has opted out of the Medicare program must sign this agreement and agree to be financially responsible for the entire cost of any services received. Neither the provider nor the patient can submit a bill to Medicare for reimbursement.Opt-out agreements last for two consecutive years and are automatically renewed every two years. According to CMS , physicians and other practitioners are not allowed to opt-out of Medicare if they are a Medicare Advantage provider or furnish services covered by traditional Medicare Part B. Providers who have opted-out of the Medicare program must enter a private contract with each of their Medicare patients that states that neither party is allowed to receive payment from Medicare for the services performed.

What Share of Physicians Have Opted Out of Medicare?

1.1 percent of non-pediatric physicians have formally opted-out of the Medicare program.  As of June 2023, 11,039 non-pediatric physicians have opted out of Medicare, representing a very small share (1.1%) of the total number active physicians, similar to the shares  reported in 2013 and 2022 .

While the overall opt-out rate is 1.1 percent, opt-out rates are somewhat higher for certain specialties, such as psychiatry and plastic and reconstructive surgery.   In 2023, 7.7 percent of psychiatrists opted out of Medicare, followed by 4.2 percent of physicians specializing in plastic and reconstructive surgery and 2.8 percent of physicians specializing in neurology (Figure 2).

Psychiatrists are disproportionately represented among the 1.1 percent of active physicians who have opted out of Medicare. Psychiatrists account for the largest share (40%) of opt-out physicians, followed by physicians in family medicine (21%), internal medicine (12.6%), and obstetrics/gynecology (6%) (Figure 3).

Figure 3: Among All Physicians Opting-Out of Medicare in 2023, Psychiatrists Account For Largest Share of Opt-Out Providers

Figure 3: Among All Physicians Opting-Out of Medicare in 2023, Psychiatrists Account For Largest Share of Opt-Out Providers

In addition to physicians, another 4,229 select clinical professionals with doctorate degrees (i.e. oral surgeons, podiatrists, and optometrists) have also opted-out of the Medicare program, with oral surgeons accounting for the vast majority (94%) of this group (Table 1).

Less than two percent of physicians have opted-out of Medicare in all but four states and the District of Columbia. As of June 2023, Alaska (3.1%), Colorado (2.3%), Wyoming (2.3%), Idaho (2.1%), and the District of Columbia (2.0%) have the highest rates of non-pediatric physicians who have opted out of Medicare, though in each case the share is below 4% (Figure 4). Nine states (Wisconsin, Ohio, Mississippi, Iowa, Minnesota, Nebraska, South Dakota, West Virginia, and North Dakota) have less than 0.5% of non-pediatric physicians opting out of Medicare.

This analysis shows that a very small share of non-pediatric physicians are opting-out of Medicare, similar to prior analyses dating back to 2013 . Notably, psychiatrists have the highest opt-out rates and are disproportionately represented among physicians who have opted out of Medicare in 2023. This is consistent with  previous analyses  that found that psychiatrists are less likely than other physician specialties to accept new patients with Medicare or private insurance, suggesting that psychiatrists may prefer to be paid directly from patients rather than insurers, to avoid the administrative burden and have the flexibility to charge higher fees.

This analysis also finds little state-level variation in the percent of physicians opting-out, with virtually all states having opt out rates below 2%. Despite questions about whether lower fees in Medicare relative to private insurance may discourage physicians from seeing Medicare patients, very few physicians are choosing to opt out of Medicare, which could be explained by several factors. The aging of the U.S population, and consequently, the increase in number of Medicare beneficiaries, means that for many physicians, older adults with Medicare coverage account for a relatively large share of their patient population and revenues. For these physicians, the loss of revenue resulting from opting out of Medicare would be substantial, notwithstanding the difference in payment rates between Medicare and private insurance or self-pay. Other factors, such as physician-level characteristics (e.g., years of practice and age), practice-level characteristics (e.g., solo versus group practices), and patient-level factors (e.g., average income of individuals in an area) may also play a role in physician decision-making.

Nancy Ochieng is with KFF. Gabrielle Clerveau was with KFF at the time this brief was written.

Also of Interest

  • Most Office-Based Physicians Accept New Patients, Including Patients With Medicare and Private Insurance
  • FAQs on Mental Health and Substance Use Disorder Coverage in Medicare
  • How Medicare’s New Drug Price Negotiation Program Could Expand Access to Selected Drugs

Does Medicare cover eating disorder treatment? Yes, but certain restrictions apply

Women in a group therapy session

We often think of eating disorders like anorexia nervosa or bulimia as conditions that teenagers or young adults struggle with. The National Eating Disorder Association (NEDA) estimates that about 28.8 million Americans will suffer from an eating disorder at some point in their lives. Eating disorders have one of the highest illness and death rates among all mental illnesses , with anorexia having the highest death rate of all psychiatric disorders.

But it’s not just younger people that suffer from these conditions. Older adults are susceptible to eating disorders too. Research shows that about 4% of community dwelling women over the age of 60 have indications of an eating disorder, which suggests that this is a lifelong issue. About 60% of those affected also have other concurrent psychiatric conditions, and more than one in five (21%) of older people die because of an eating disorder.

Eating disorders also affect physical health. A 2022 study found that Medicare beneficiaries with eating disorders had higher rates of other chronic conditions, including heart arrhythmias , arthritis, and thyroid conditions, compared to beneficiaries without eating disorders. Spending was higher for enrollees with eating disorders compared to those without ($29,456 vs. $7,418) regardless of health care setting. Many beneficiaries were eligible for both Medicare and Medicaid.

“While individuals under age 65 comprise roughly 16% of all Medicare enrollees, they represent approximately 42% of enrollees with any eating disorder diagnosis, a reflection of the extent to which many individuals with eating disorders are qualifying for Medicare due to disability status,” researchers found. However, about one-third of the study sample who had OSFED (36.5%) or anorexia nervosa (36.4%) were over age 75.

Unfortunately, many older adults often go undiagnosed or untreated because symptoms of eating disorders, like diarrhea, vomiting, or hair loss, might be attributed to medication side effects, or just the challenges of aging. There’s also still stigma associated with both eating disorders and with mental health treatment among some older people.

“Having an eating disorder is not a choice. It’s a serious and potentially life-threatening condition that can lead to heart attacks, kidney failure, osteoporosis, and electrolyte imbalances,” writes Amy Puccini , a dietetic intern at Oregon Health Sciences University .

Are eating disorders covered by Medicare?

Eating disorder treatments and therapies are considered mental health treatment, and are covered under Medicare’s mental health coverage. Medicare will pay for counseling and treatment, including short-term inpatient care, outpatient care, and psychotherapy or drug maintenance. A physician must demonstrate that treatment is medically necessary for therapy. Partial hospitalization , which is an alternative to inpatient care, is also covered when provided through a hospital’s outpatient department or community mental health center.

“The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)—a federal law that requires health insurers to provide mental health or substance use disorder coverage on par with physical medical diagnoses, excludes any other levels of care that are often required for mental health conditions like eating disorders,” according to Project Heal , a nonprofit that addresses the systemic and financial barriers to eating disorder treatment.

Medicare also does not cover medical nutrition therapy solely for eating disorders, but a bipartisan bill was reintroduced in the Senate in November by Maggie Hassan (D-N.H.) and Lisa Murkowski (R-Ark.) would change that. The Nutrition CARE Act would expand access to medical care for Medicare beneficiaries with eating disorders by including coverage of outpatient medical nutrition therapy through Medicare Part B , which would provide patients with a more comprehensive, specialized approach to combating eating disorders than what is currently offered under Medicare. 

“It is critical that people on Medicare with an eating disorder can get the full help that they need,” Hassan said in a statement.

What traditional Medicare covers

  • Anorexia nervosa , unspecified
  • Anorexia nervosa, restricting type
  • Anorexia nervosa , binge eating/purging type
  • Bulimia nervosa
  • Binge eating disorder
  • Avoidant/restrictive food intake disorder (ARFID)
  • Other specified eating disorders (OSFED)
  • Eating disorders, unspecified

Eating disorders are treatable with the right care and counseling , according to Beverly Smith, Ph.D., the CEO and executive director of the American Mental Health Counselors Association . New Medicare payment rules allow for licensed mental health counselors to accept Medicare assignment , increasing beneficiary access to thousands of additional trained mental health professionals, who can help coordinate care.

“Eating disorders are often discussed and treated in collaboration with other professionals to foster a wholistic approach to sustainable treatment. As mental health care professionals, we help the patient by trying to help discover the root causes [and] triggers, and enhance coping skills already developed,” Smith says. “A key piece of treatment is helping to establish accountability groups or partners as well as having open conversations about relapse with the awareness that it is okay not to be perfect.”

More help for eating disorders

If you or someone you love has an eating disorder, you can contact:

  • National Alliance for Eating Disorders Helpline
  • The National Association of Anorexia Nervosa & Associated Disorders (ANAD) Helpline  
  • The Crisis Text Line : text HOME to 741741
  • Eating Disorders Anonymous  

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Provider Assignment

On this page:, provider nomination and the geographic assignment rule.

  • Part A and Part B (A/B) and Home Health and Hospice (HH+H)
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
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  • Qualified Chains
  • Out-of-Jurisdiction Providers (OJP)

Section 911(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Public Law 108-173 , repealed the provider nomination provisions formerly found in Section 1816 of the Title XVIII of the Social Security Act and replaced it with the Geographic Assignment Rule.  Generally, a provider or supplier will be assigned to the Medicare Administrative Contractor (MAC) that covers the state where the provider or supplier is located. The Center for Medicare & Medicaid Services’ (CMS) has defined the following approach for assigning providers, physicians, and suppliers to MACs.

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Part A/Part B (A/B) and Home Health and Hospice (HH+H) Rule

All A/B and HH+H providers will be assigned to the MAC contracted by CMS to administer A/B and HH+H claims for the geographic locale in which the provider is physically located.  Learn more about the current A/B MAC jurisdictions and HH+H areas and view the corresponding maps at Who are the MACs.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Rule

Each DMEPOS supplier submits claims to the DME MAC contracted by CMS to administer DMEPOS claims for the geographic locale in which the beneficiary resides permanently.  Learn more about the current DME MAC jurisdictions and view the corresponding map at Who are the MACs.

Specialty Providers and Demonstrations Rule

Specialty providers and providers involved with certain demonstrations will submit claims to a specific MAC designated by CMS.  Learn more about a specific A/B MAC or DME MAC and view the corresponding maps at Who are the MACs .

Railroad Retirement Beneficiaries Entitled to Medicare Rule

Physicians and other suppliers (except for DMEPOS suppliers) will continue to enroll with and bill the contractor designated by the Railroad Retirement Board for Part B services furnished to their beneficiaries.  Each DMEPOS supplier will submit claims to the DME MAC contracted by CMS to administer DMEPOS claims for the geographic locale in which the beneficiary resides permanently.  Learn more about the current DME MAC jurisdictions and view the corresponding map at W ho are the MACs.

Qualified Chains Rule

The Geographic Assignment Rule states that generally, a provider or supplier will be assigned to the MAC that covers the state where the provider or supplier is located.  However, it does provide an exception for qualified chains.  A qualified chain home office may request that its hospitals and skilled nursing facilities be serviced by the A/B MAC that covers the state where the home office is located.  A qualified chain home office may send an inquiry to:   CMS [email protected]

Out-of-Jurisdiction Providers (OJP) Rule

An OJP is a provider that is not currently assigned to an A/B MAC in accordance with the geographic assignment rule and the qualified chain exception.  For example, a hospital not part of a qualified chain located in Maine, but currently assigned to the A/B MAC in Jurisdiction F would be an OJP.

Each A/B MAC will initially service some OJPs until CMS undertakes the final reassignment of all OJPs to their destination MACs based on the geographic assignment rule and its exceptions.

CMS has not set a timetable for moving OJP’s.

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COMMENTS

  1. Does your provider accept Medicare as full payment?

    If your doctor, provider, or supplier doesn't accept assignment: You might have to pay the full amount at the time of service. They should submit a claim to Medicare for any Medicare-covered services they give you, and they can't charge you for submitting a claim. If they refuse to submit a Medicare claim, you can submit your own claim to Medicare.

  2. 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.

  3. What Is Medicare Assignment and How Does It Affect You?

    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 he or she can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive.

  4. Medicare Assignment

    When Medicare assignment is accepted, it means your doctor agrees to the payment terms of Medicare. Doctors that accept Medicare assignment fall under one of three designations: a participating doctor, a non-participating doctor, or they opt-out of the program altogether.

  5. Medicare Assignment: What It Is and How It Works

    Here's how it works: Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment. The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as ...

  6. Assignment and Non-assignment of Benefits

    Nonparticipating suppliers have the option of accepting assignment on a claim-by-claim basis except where CMS regulations require mandatory assignment, i.e., Medicare covered drugs.

  7. Assignment and Nonassignment of Benefits

    Item 27 on the CMS-1500 claim form allows the provider to indicate whether they accept or do not accept assignment. When accepting assignment, the beneficiary may be billed for the 20% coinsurance, any unmet deductible and for services not covered by Medicare.

  8. Participating, non-participating, and opt-out Medicare providers

    Non-participating providers accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare's approved amount for health care services as full payment.

  9. Everything PTs Need to Know About Accepting Medicare Assignment

    Non-participating providers may choose to accept assignment for some services, but not others —or no services at all. For services that are not under assignment, the provider may collect payment directly from the patient; however, he or she must still bill Medicare, so that Medicare may reimburse the patient. The Pros

  10. Paying a Visit to the Doctor: Current Financial Protections for ...

    When non-participating providers do not accept assignment, they may not collect reimbursement from Medicare; rather, they bill the Medicare patient directly, typically up front at the time of service.

  11. What to Do When Your Doctor Doesn't Take Medicare

    1. Stay Put and Pay the Difference If your doctor is what's called a non-participating provider, it means they haven't signed an agreement to accept assignment for all Medicare-covered...

  12. MLN9658742

    Medicare participation means you agree to accept claims assignment for all covered patient services. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You can't collect more from the patient than the deductible and coinsurance or copayment.The Social Security Act says you must submit patient Medicare claims whether or not you participate.

  13. Medicare Assignment: What It's About, and Who It Affects

    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.

  14. What is Medicare Assignment

    September 22, 2023 • min read • Written by Anna Porretta Back Summary: Medicare Assignment is an agreement between healthcare providers and Medicare, where providers accept the Medicare-approved amount as full payment, preventing them from charging beneficiaries extra.

  15. Medicare Assignment and How Doctors Accept It Explained

    Those who have not signed a contract with Medicare can still accept assignment amounts for services of their choice. They do not have to accept assignment for every service provided. These are called non-participating providers. Some providers opt out of Medicare altogether.

  16. Medicare Assignment: Understanding How It Works

    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

  17. PDF Frequently asked questions

    When they accept assignment, Medicare makes the payment directly to the physician and collects the 20 percent coinsurance from the patient, but the physician cannot collect the full limiting charge amount. For unassigned claims, Medicare reimburses the patient and the physician collects the entire limiting charge amount from the patient.

  18. Medicare Assignment: How to Choose the Right Provider

    A non-participating provider can choose to accept or not accept assignment on Medicare-covered services. If your provider is non-participating, you could be liable for the entire amount of your services. Additionally, service providers can charge you up to 15% more than the Medicare-approved amount, even when they accept assignment for a ...

  19. Medicare Assignment: What Does Accepting Assignment Mean?

    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.

  20. Physician Acceptance of Medicare Assignment

    What May Happen When a Provider Doesn't Accept Assignment? In addition to possibly being charged up to an additional 15% for procedures and services, individuals who use non-participating providers may be required to pay full costs for services upfront.

  21. Annual Medicare Participation Announcement

    Medicare "participation" means you agree to accept claims assignment for all Medicare-covered services to your patients. By accepting assignment, you agree to accept Medicare-allowed amounts as payment in full. You may not collect more from the patient than the Medicare deductible and coinsurance or copayment. Participating Provider or ...

  22. How Many Physicians Have Opted Out of the Medicare Program?

    Less than two percent of physicians have opted-out of Medicare in all but four states and the District of Columbia. As of June 2023, Alaska (3.1%), Colorado (2.3%), Wyoming (2.3%), Idaho (2.1% ...

  23. Does Medicare cover eating disorder treatment? Yes, but certain

    New Medicare payment rules allow for licensed mental health counselors to accept Medicare assignment, increasing beneficiary access to thousands of additional trained mental health professionals, ...

  24. Provider Assignment

    Section 911 (b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Public Law 108-173, repealed the provider nomination provisions formerly found in Section 1816 of the Title XVIII of the Social Security Act and replaced it with the Geographic Assignment Rule.

  25. Federal Register :: Medicare Program; Strengthening Oversight of

    Proposed § 489.57(b)(3) would require that during the time period in which a provider or supplier is terminated from the Medicare program, is under the oversight of the SA, and during the time the new agreement for Medicare participation is pending, CMS will not accept or recognize deeming accreditation from a CMS-approved accrediting ...