Index

About Medicare Supplement

Eligibility and Enrollment

The Prescription Drug Program

Other Plan Provisions

Covered Expenses

Exclusions

Coordination of Benefits

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Accepting Assignment

Q. What does it mean if a doctor accepts assignment?

A. Medicare determines and approves payment amounts for its covered health care services and supplies. If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for that service or supply. You must still pay the difference between the Medicare-approved amount and the amount Medicare and the Plan pay (percentage co-payment).

If a doctor does not accept assignment, you may be required to pay the full amount of the bill when you receive the service. Medicare will then reimburse you for its share of the bill.

All doctors and medical suppliers must accept assignment in some situations, for example, for clinical laboratory services covered by Medicare.

Limiting Charge

Medicare sets a limiting charge — 15% over Medicare's approved payment amount. As a general rule, doctors and other health care providers who do not accept assignment may not require you to pay more than 15% over the Medicare-approved amount. Under provisions of the Social Security Act Amendments of 1994, you are not liable for and do not owe amounts billed in excess of Medicare's limiting charge (115% of the Medicare-approved amount).

Exceptions are services you get from doctors with whom you have a private contract, or for certain items and services, such as vaccinations, ambulance services and durable medical equipment. A private contract is an agreement between you and your doctor who has decided not to give services through the Medicare program. In these situations, you may be required to pay the full amount of the bill when you receive the service.

Examples

Example 1 — A Physician Who Accepts Assignment:
In this example, the physician accepts the Medicare-approved amount. The physician's regular fee for this service is $2,100. The Medicare-approved amount for this service is $1,500. You have met all the deductibles for the year.

How the Benefit Is Calculated
Medicare pays 80% of its approved amount.

The Results
Payment of the physician's fee is as follows:

The payments total $1,500. Because the physician accepts assignment, he or she, in effect, reduces the original fee by $600.

Example 2 — A Physician Who Does Not Accept Assignment
We change the preceding example in one important way: The physician does not accept Medicare assignment and submits a fee of $2,100. The Medicare-approved amount for this service is $1,500. Medicare's limiting charge for physicians who do not accept Medicare assignment is 115% of the Medicare-approved amount or $1,725.

How the Benefit Is Calculated
Medicare pays 80% of its approved amount. Medicare pays:

The Results
Payment of the physician's fee is as follows: