Jeffrey Wade
Medicare beneficiaries often enjoy the benefit of choosing any doctor or clinician across the country, but this only applies to doctors who accept Medicare assignment. Doctors who accept Medicare assignment agree to accept payment from Medicare for their services. If you have a Medicare Supplement Insurance (Medigap) plan, you may be able to see the doctor of your choice, but only if they accept Medicare assignment. Medigap plans won't pay for service costs from doctors who don't accept assignment. If you have a Medicare Advantage plan, you may be required to see in-network doctors with few exceptions. Opt-out providers do not accept Medicare at all and can charge whatever they want for services. Medicare won't pay for care received from an opt-out provider, except in emergencies.
| Characteristics | Values |
|---|---|
| Medicare-approved amount as full payment | "Accepting assignment" |
| Out-of-pocket costs | Less |
| Patient's responsibility | Medicare deductible and coinsurance amount |
| Submission of claim | Direct submission to Medicare |
| Medicare-covered services | Submission of claim to Medicare |
| Non-participating providers | Accept Medicare assignment on a case-by-case basis |
| Opt-out providers | Do not accept Medicare at all |
| Medigap supplemental insurance | Only with Medicare |
| Medicare Advantage plans | Use provider networks |
| Medicare SELECT Supplement plan | Must stay within the network to receive benefits |
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What You'll Learn
Medicare-approved providers
Non-participating providers are doctors or providers who have not signed a Medicare agreement but are eligible to accept Medicare on a case-by-case basis. If you visit a non-participating provider, be sure to ask if they accept Medicare for your specific service.
Medicare Advantage (Part C) plans often use provider networks, which are groups of doctors and providers in an area that have agreed to treat an insurance company's customers. If you have a Part C plan, you may be required to see in-network doctors, with some exceptions.
Medicare Supplement Insurance, also known as Medigap, requires a separate assignment of benefits form for reimbursement. Medigap plans will not pay for service costs from doctors who do not accept Medicare assignment. It's important to note that Medigap cannot be used in conjunction with a Medicare Advantage plan.
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Non-participating providers
Non-participating physicians who do not accept assignment for services that are determined to be unnecessary must refund any amounts collected for those services to the patient, unless the patient has signed an Advanced Beneficiary Notice (ABN). The government requires all Medicare carriers to monitor compliance with the rules and restrictions. Failure to comply may result in fines, penalties, and/or exclusion from the Medicare and Medicaid programs.
Medigap Supplemental Insurance (Medigap) plans won’t pay for service costs from doctors who don’t accept assignment. If you have a Medigap plan, you may also need to sign a separate assignment of benefits form for Medigap reimbursement.
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Opt-out providers
Doctors or other healthcare 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 a provider that opts out, except in emergencies. Providers who opt out do so for a minimum period of two years. Every two 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. Opting out means a provider cannot be involved in any Medicare program, including original fee-for-service Medicare, Medicare Managed Care Plans, Medicare+Choice Plan, and Medicare Advantage Plan.
To prescribe drugs covered by a Medicare Advantage Plan, providers must enroll in Medicare. Providers eligible to prescribe Part D drugs and order/certify may submit the CMS 855O. Providers cannot be opted out for some services and not others, as well as some locations and not others. An affidavit must be filed with all carriers who have jurisdiction over claims the physician/practitioner would otherwise file with Medicare. The opt-out period lasts two years and auto-renews at the end of the two-year period without needing to resubmit an updated affidavit. If a provider wishes to cancel the automatic renewal extension, they must notify the MAC in writing at least 30 days prior to the start of the next two-year opt-out.
If a provider has opted out of Medicare, they are opted out across the United States of America and its territories. If a provider goes from one MAC to another, an additional opt-out affidavit is required to be submitted to the new MAC. For example, if a provider sees a patient in South Dakota and then sees a patient in Iowa, the provider is required to submit an opt-out affidavit to the MAC that oversees Iowa.
If a provider has elected to opt out of Medicare, they cannot bill for any current patients or clients for any reason except for emergency situations. In order to bill for these services, the provider will need to fully enroll. Submit an application for enrollment via the Provider Enrollment Chain and Ownership System (PECOS) or a paper CMS-855I application. Once the Provider Transaction Access Number (PTAN) has been received, claims must be submitted for any emergency or urgent care service(s) provided.
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Medigap Supplemental Insurance (Medigap) plans
Medigap, also known as Medicare Supplement Insurance, is an additional insurance plan that can be purchased from a private health insurance company. It helps pay for out-of-pocket costs that Original Medicare (Part A and Part B) does not cover. It's important to note that Medigap is not available if you have a Medicare Advantage Plan.
When you buy a Medigap policy, you generally need to have Medicare Part A and Part B, and you will be required to pay the monthly premium for both. The Medigap policy will then pay its share of the covered health care costs, along with Medicare. As long as you continue to pay your premiums, your Medigap policy is guaranteed to be renewable automatically each year. However, it's worth noting that insurance companies in some states may refuse to renew Medigap policies purchased before 1992.
Medigap policies must adhere to federal and state laws, and they offer standardized coverage. These policies can vary in cost, so it's important to compare them before purchasing. Additionally, some Medigap policies provide extra benefits that aren't typically covered by Medicare.
It is important to understand that Medigap Supplemental Insurance (Medigap) plans will only pay for service costs from doctors who accept "assignment." Doctors who accept assignment have agreed to accept Medicare reimbursement rates for covered services, which helps keep your out-of-pocket costs within your control. Most doctors accept Medicare assignment, but it's always a good idea to check beforehand.
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Medicare SELECT plans
With a Medicare SELECT plan, you may be required to receive a referral from your primary care physician before seeking treatment from a specialist. This is another difference from Original Medicare and Medicare Supplement plans, which do not require referrals.
To be eligible for Medicare SELECT, you must be eligible for Medicare Part A and live within the service area of the Medicare SELECT plan.
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Frequently asked questions
No, not all medical providers accept Medicare. If a provider accepts Medicare, they are considered a "participating provider".
Medicare "assignment" refers to whether or not a doctor accepts the Medicare payment as payment in full. Most providers do accept Medicare assignment, but specialists are the largest group that does not.
Participating providers have signed a participation agreement stating they will accept Medicare reimbursement rates for their services. Non-participating providers are eligible to accept Medicare but have not signed a Medicare agreement. They may choose to accept Medicare on a case-by-case basis.
With most types of Medicare Supplement plans, you can see the doctor of your choice. However, some states offer Medicare SELECT, a type of Medicare Supplement plan with a specific network of hospitals and doctors. If you enroll in Medicare SELECT, you may have to use in-network doctors for non-emergency care to receive full insurance benefits.
