Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
Make sure your doctor, provider, or supplier accepts assignment
Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Participating providers have signed an agreement to accept assignment for all Medicare-covered services.
Here's what happens if your doctor, provider, or supplier accepts assignment:
- Your may be less.
- They agree to charge you only the Medicare and amount and usually wait for Medicare to pay its share before asking you to pay your share.
- They have to submit your directly to Medicare and can't charge you for submitting the claim.
Almost all prescribers need to be enrolled in Medicare or have an “opt-out” request on file with Medicare for your Medicare drug plan to cover your prescriptions. If your prescriber isn’t enrolled and hasn't “opted-out,” you’ll still be able to get a 3-month provisional fill of your prescription. This will give your prescriber time to enroll, or you time to find a new prescriber who’s enrolled or has opted-out. Contact your plan or your prescribers for more information.
If your doctor, provider, or supplier doesn't accept assignment
Non-participating providers haven't signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. These providers are called "non-participating."
Here's what happens if your doctor, provider, or supplier doesn't accept assignment:
- You might have to pay the entire charge at the time of service. Your doctor, provider, or supplier is supposed to submit a claim to Medicare for any Medicare-covered services they provide to you.
- They can't charge you for submitting a claim. If they don't submit the Medicare claim once you ask them to, call 1‑800‑MEDICARE.
- In some cases, you might have to submit your own claim to Medicare using Form CMS-1490S to get paid back.
- They can charge you more than the Medicare-approved amount, but there's a limit called "the ". The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
The limiting charge applies only to certain Medicare-covered services and doesn't apply to some supplies and durable medical equipment.
Not sure if your doctor is covered by Medicare?
What to know about private contracts
Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you get from an opt-out doctor or other provider, except in the case of an emergency or urgent need. If you still want to see an opt-out provider, you and your provider can set up payment terms that you both agree to through a private contract.
A doctor or other provider who chooses to opt-out must do so for two years, which automatically renews every two years unless the provider requests not to renew their opt-out status. If you want to find an “opt out” provider, visit data.cms.gov/opt-out-affidavits. You can look up a provider by their National Provider Identifier (NPI), or by first and last name.
Rules for private contracts
You don't have to sign a private contract. You can always go to another provider who gives services through Medicare. If you sign a private contract with your doctor or other provider, these rules apply:
Medicare won't pay any amount for the services you get from this doctor or provider, even if it's a Medicare-covered service.
- You'll have to pay the full amount of whatever this provider charges you for the services you get. You and your provider will set up your own payment terms through the contract.
- If you have a Medicare Supplement Insurance (Medigap) policy, it won't pay anything for the services you get. Call your insurance company before you get the service if you have questions.
- Your provider must tell you if Medicare would pay for the service if you got it from another provider who accepts Medicare.
- Your provider must tell you if he or she has been excluded from Medicare.
- You can't be asked to sign a private contract for emergency or urgent care.
- You're always free to get services not covered by Medicare if you choose to pay for a service yourself.
You may want to contact your State Health Insurance Assistance Program (SHIP) to get help before signing a private contract with any doctor or other health care provider.