medicare mandatory assignment

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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 Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

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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.

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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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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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Medicare Assignment: Providers, benefits, considerations

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. This benefits Medicare beneficiaries by controlling their costs and ensuring they only pay deductibles and copayments. Providers who accept Assignment gain access to Medicare patients and timely reimbursement. However, providers have the choice to opt out, potentially leading to excess charges for beneficiaries. It is important for beneficiaries to choose providers who accept Assignment to minimize out-of-pocket expenses.

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What is Medicare Assignment?

Medicare assignment refers to healthcare providers agreeing to accept the Medicare-approved amount as full payment for covered services. It applies primarily to Original Medicare (Parts A and B) and certain Medicare Advantage plans. By accepting assignment, providers agree not to charge beneficiaries more than the approved rates, limiting out-of-pocket expenses.

Beneficiaries are responsible for deductibles, coinsurance, and copayments. Not all providers accept assignment, which may result in higher costs. To avoid excess charges, it’s advisable to choose providers who accept Medicare assignment by using online tools or contacting the Medicare Advantage plan for in-network options.

How does Medicare Assignment work?

Medicare assignment simplifies the payment process for Medicare beneficiaries. When healthcare providers accept assignment, they agree to charge the Medicare-approved amount for covered services. This applies to Original Medicare ( Part A and Part B ) and select Medicare Advantage plans. When a beneficiary receives medical care, the provider submits the claim to Medicare for payment. Medicare reviews the claim, determines the approved amount based on its fee schedule, and pays the provider directly. Beneficiaries are then responsible for their share of the costs, such as deductibles, coinsurance, and copayments. By accepting assignment, providers ensure that beneficiaries are protected from excessive charges and have more predictable out-of-pocket expenses.

However, it’s important to note that not all providers accept assignment. In such cases, beneficiaries may be responsible for excess charges, which can result in higher costs. To avoid these charges, beneficiaries are encouraged to choose healthcare providers who accept Medicare assignment. Overall, Medicare assignment streamlines the payment process, promotes cost transparency, and helps beneficiaries access necessary healthcare services while keeping their out-of-pocket expenses manageable.

Medicare Assignment and doctors

Doctors and healthcare providers can choose to participate in Medicare assignment by signing the Medicare Participating Provider Agreement. By accepting assignment, they agree to the Medicare-approved payment rates for services provided to Medicare beneficiaries, which helps limit out-of-pocket expenses for beneficiaries. Providers who do not sign the agreement are considered non-participating and have more flexibility in setting fees, potentially resulting in higher costs for beneficiaries.

Participating providers

When doctors participate in Medicare Assignment, it means they have signed the Medicare Participating Provider Agreement and agree to accept the Medicare-approved amount as full payment for covered services rendered to Medicare beneficiaries. By accepting assignment, these providers help limit the out-of-pocket expenses for Medicare beneficiaries, as they cannot charge more than the approved amount for services.

Additionally, participating providers who accept Medicare Assignment often also accept Medigap ( Medicare Supplement Insurance) plans. Medigap plans are private insurance policies that help cover some of the costs that Original Medicare (Parts A and B) doesn’t pay, such as deductibles, coinsurance, and copayments. Doctors who participate in Medicare Assignment are often preferred by Medigap policyholders because they are more likely to accept the Medicare-approved amount as payment, reducing the potential for excess charges and minimizing out-of-pocket costs for beneficiaries with Medigap coverage.

Non-participating providers

When doctors don’t participate in Medicare Assignment, it means they have chosen not to sign the Medicare Participating Provider Agreement. As non-participating providers, they have more flexibility in setting their fees for services provided to Medicare beneficiaries. This means they can charge their regular fees, which may be higher than the Medicare-approved amount.

When beneficiaries receive services from non-participating providers, Medicare still covers its portion of the approved amount (usually 80% for Part B services), but the beneficiary may be responsible for a greater share of the costs. Non-participating providers can charge beneficiaries up to 15% more than the Medicare-approved amount, resulting in excess charges. These excess charges are the responsibility of the beneficiary and are not covered by Medicare.

It’s important for Medicare beneficiaries to be aware that choosing non-participating providers can result in higher out-of-pocket costs. However, beneficiaries still have the option to see non-participating providers if they are willing to pay the additional charges.

Opt-out providers

When doctors choose to “opt-out” of Medicare Assignment, it means they have decided not to participate in the Medicare program altogether. Opt-out providers do not accept Medicare at all, and they are not bound by Medicare’s rules and regulations, including the Medicare fee schedule.

Opting out of Medicare allows doctors to set their own fees and terms of service independently. They can establish their payment structure, which may be different from the Medicare-approved rates. Opt-out providers typically require patients to sign private contracts stating that they understand the doctor does not participate in Medicare and agree to pay for services out-of-pocket.

If a beneficiary seeks services from an opt-out provider, Medicare will not provide any coverage for those services. The beneficiary becomes solely responsible for the full cost of the care received. Consequently, the services provided by opt-out providers are not reimbursed or eligible for Medicare benefits.

How do I find a doctor that accepts assignment?

When looking for a doctor that accepts Medicare assignment, consider the following key steps and considerations:

• Use the Medicare Physician Compare Tool: Medicare provides a helpful online tool called “Physician Compare” that allows you to search for doctors, specialists, and other healthcare providers who accept Medicare assignment. You can access this tool on the official Medicare website and search based on your location and medical needs.
• Contact Medicare Advantage Plan: If you are enrolled in a Medicare Advantage plan (Part C), reach out to your plan provider for a list of in-network doctors that accept assignment. Medicare Advantage plans have their own network of healthcare providers, and they can provide you with the most up-to-date information on which doctors are in-network and accept Medicare assignment.
• Talk to Your Current Doctor: If you have a preferred doctor or healthcare provider, you can directly ask them if they accept Medicare assignment. They can inform you about their participation status and whether they accept assignment for Medicare beneficiaries.
• Seek Referrals and Recommendations: Consult with friends, family members, or other trusted individuals who are Medicare beneficiaries and ask for recommendations for doctors that accept assignment. They may be able to provide insights based on their own experiences and help you find suitable healthcare providers.
• Contact Local Medical Associations: Local medical associations or organizations may have resources or directories that can provide information about doctors accepting Medicare assignment in your area. They can assist in narrowing down your search and provide relevant details.
• Verify Participation with the Doctor’s Office: Once you identify potential doctors, contact their offices directly and inquire about their participation status in Medicare assignment. Confirm that they accept assignment and are currently taking new Medicare patients.

Benefits of Medicare Assignment

The Medicare Assignment program offers several benefits to beneficiaries, including:

• Predictable Expenses: Medicare assignment provides cost transparency and predictability. Since participating providers adhere to the Medicare fee schedule, beneficiaries can have a clearer understanding of the expected costs for medical services. This allows them to plan and budget their healthcare expenses more effectively.
• Reduced Paperwork: With Medicare assignment, beneficiaries experience simplified paperwork and claims processing. Participating providers submit claims directly to Medicare on behalf of the beneficiary, eliminating the need for the beneficiary to file claims themselves. This streamlines the reimbursement process and reduces administrative burdens.
• Access to Quality Providers: Many healthcare providers, including doctors, hospitals, and other professionals, accept Medicare assignment. By choosing participating providers, beneficiaries have access to a wide network of qualified and experienced healthcare professionals who are committed to providing care at the Medicare-approved rates. This ensures that beneficiaries receive high-quality healthcare services without worrying about excessive charges.
• Medigap Compatibility: Medicare assignment aligns well with Medigap (Medicare Supplement Insurance) plans. Medigap plans help cover some of the costs that Original Medicare doesn’t pay, such as deductibles, coinsurance, and copayments. When beneficiaries visit participating providers who accept assignment, they are more likely to receive services within the Medicare-approved amount, reducing the potential for excess charges and making their Medigap coverage more effective.

Overall, the benefits of Medicare assignment include cost savings, predictability of expenses, simplified paperwork, access to quality providers, and enhanced compatibility with Medigap plans. By choosing participating providers, beneficiaries can optimize their healthcare experience and minimize their financial burden.

Frequently asked questions

• What is the difference between Medicare participation and Medicare assignment?

Medicare participation refers to healthcare providers enrolling in the Medicare program and agreeing to treat Medicare beneficiaries. Medicare assignment, on the other hand, specifically relates to providers accepting the Medicare-approved amount as full payment for covered services. In short, participation is about being part of the Medicare program, while assignment refers to accepting the Medicare-approved amount as payment.

• Is Medicare Assignment the same as Medicare?

No, Medicare Assignment is not the same as Medicare.

• What percentage of doctors do not accept Medicare assignment?

The exact percentage of doctors who do not accept Medicare assignment can vary, but it is estimated that around 10-15% of doctors in the United States do not accept Medicare assignment.

Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealth’s Medicare related content is compliant with CMS regulations, you can rest assured you’re getting accurate information so you can make the right decisions for your coverage. Read more to learn about our Compliance Program.

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Enrollment guide: Chapter 4 - Medicare participation

4 medicare participation, 4.1 overview, 4.2 part a provider participation and content and terms of provider participation agreements, 4.3 part b physician / practitioner / supplier participation agreement and assignment, 4.4 part b participation eligibility, 4.5 part b participation specifics.

To be a participating provider under Medicare, a provider must be in compliance with the applicable provisions of title VI of the Civil Rights Act of 1964 and must enter into an agreement under §1866 of the Act which provides that it will:

Institutional providers that bill Part A are paid directly by the A / B MAC . In contrast, physicians, practitioners, and suppliers that bill Part B may choose to enter into a participation agreement. CMS SOG location use the provider tie-in notice as an official notification to the Fiscal Intermediary (FI) or A / B MAC of a change in its list of providers. The SOG location completes and transmits a tie-in notice to the home office of the FI or A / B MAC in each of the following circumstances:

In the agreement / attestation statement signed by a provider serviced by an FI or A / B MAC, the provider agrees to maintain its compliance with all of the conditions for certification in 42 CFR 491. If a provider fails to maintain compliance with one or more of the conditions, it must promptly report this (usually within 30 days of the failure) to the responsible CMS office or official. Failure to report promptly may be a cause for termination of the provider's agreement.

In the agreement / attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary's behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for which the beneficiary would have been entitled to have payment made had the provider filed a request for payment.

The provider may bill the beneficiary for the following items:

To review all rules and regulations related to participation, click here .

Part B "participating providers" are paid at 100 percent of the physician fee schedule and must accept assignment (must accept program payment as payment in full, except for any unmet deductible and coinsurance). "Non-participating providers" are paid at 95 percent of the physician fee schedule and may accept assignment on a claim-by-claim basis. Physicians and suppliers enrolled in the Medicare program under the form CMS-855 process do not have to sign a "Medicare Participating Physician or Supplier Agreement" in order to bill Medicare and receive payment. However, there is a 5 percent reduction in the Medicare approved amounts if the physician or his / her reassignee does not participate. Participation is an election that is optional to physicians and suppliers, even those that have to bill assigned. Also, regardless of participation, some suppliers and practitioner types are required to accept assignment.

To obtain a copy of the CMS-460 Medicare participating physician or supplier agreement, click here .

All practitioners and suppliers eligible to receive payments under Part B of Medicare may choose to enter into a participation agreement. This includes practitioners whose services are subject to mandatory assignment. The reason why it could still be appropriate for such practitioners to enter into a participation agreement is because the mandatory assignment provisions apply only to the particular practitioner service benefit (e.g., nurse practitioner services).

E xample : If a nurse practitioner is eligible to bill for, and is indeed billing under, Part B for something other than a nurse practitioner service (e.g., an EKG tracing), the mandatory assignment provision of the law does not apply to that other service. However, if the nurse practitioner has entered into a participation agreement, that agreement requires that the nurse practitioner accepts assignment for any service for which he or she submits a Medicare Part B claim.

a. Why p articipate?

The benefits of signing a participation agreement include:

b. Applicable s ervices

Once a participation agreement has been signed, the participant has agreed to accept assignment for any item or services for which payment is made on a fee-for-service basis by Medicare Part B. The agreement applies in all localities and to all names and identification numbers under which the participant does business.

c. Practitioners s ubject to m andatory a ssignment

The following practitioners who provide services under the Medicare program are required to accept assignment on all Medicare claims and must accept the Medicare allowed amount as payment in full. Although these practitioners are not invited to officially enroll in the Medicare participation program, contractors treat them as participating practitioners. They are not required to sign participation agreements and are included in the Medicare Participating Directory:

N ote : The provider type mass immunization roster biller can only bill for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.

d. Services s ubject to m andatory a ssignment

Assignment is mandated for claims submitted for the following services and the Medicare allowed amount must be accepted as payment in full:

Unlike providers bound by a participation agreement, practitioners/entities providing the services / supplies identified above are required to accept assignment only with respect to these services / supplies (unless they have signed participation agreements which blanket the full range of their services).

e. Guidelines for h ospital / m edical g roups

Generally, if a hospital, medical group, or other entity bills for physicians' services in the name of the entity (i.e., the physician is not billing for his or her own services), one participation agreement signed by the entity binds all physicians for services billed by the entity. However, in university medical centers, participation decisions can be made at the departmental level, rather than having the entire medical center subject to one participation choice.

If a physician who is associated with a particular entity has an individual practice outside the scope of the practice for which the entity bills and receives payment, he or she may choose whether to participate with respect to his / her outside practice without regard to the participation status of the entity.

If the individual physicians work for an entity and receive payment in their own names for the services furnished for the entity, they make individual decisions as to whether to participate. These decisions apply both to the physicians' services for the entity and to any outside practice.

f. Length of a greement and p articipation e nrollment p eriod

Once a year, all Medicare Part B contractors conduct an enrollment period for the physicians, non-physicians and suppliers in their areas. Open enrollment is announced on  our website and materials are mailed to eligible practitioners and suppliers explaining the process. Open enrollment allows non-participants the opportunity to sign an agreement to become participating and participants the opportunity to terminate an agreement and become non-participating. If a physician or practitioner does not wish to change their participation status, no action is required during open enrollment. Once a participation agreement is signed, the participant is bound by that agreement until it is terminated in writing during an open enrollment period (the agreement is renewed automatically for each 12-month period).

g. When a n ew p hysician or s upplier m ay e nter into a greement

A physician / supplier who has enrolled in the Medicare program and wishes to become a participating physician / supplier must file an agreement with a Medicare contractor within 90 days after either of the following events:

The participant is newly licensed to practice medicine or another health care profession; or

The participant first opens offices for professional practice or other health care business in a particular contractor service area or locality (regardless of whether the participant previously had or retains offices elsewhere).

If a physician has an arrangement with a hospital, medical group, or other entity under which the entity bills in its name for his / her services, changes that arrangement and then begins to bill in his / her own name, he/she is considered to be first opening offices, even though he / she practices in the same location.

h. Durable Medical Equipment, Prosth etics, Orthotics, and Supplies (DMEPOS) and Durable Medical Equipment (DME) s uppliers

All DMEPOS and DME Suppliers shall submit the CMS 855S form to one of the provider enrollment DME contractors:

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Mandatory Claims Submission and its Enforcement

The Social Security Act (Section 1848(g)(4)) requires that claims be submitted for all Medicare patients for services rendered on or after September 1, 1990. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries, and the requirement to submit Medicare claims does not mean physicians or suppliers must accept assignment.

Download the Guidance Document

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: May 07, 2009

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.

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2024-05-09-MLNC

Thursday, May 9, 2024

HHS Releases New Data Showing Over 10 million People with Medicare Received a Free Vaccine Because of the President’s Inflation Reduction Act; Releases Draft Guidance for the Second Cycle of Medicare Drug Price Negotiation Program

Cms roundup (may 3, 2024), medicare shared savings program: prepare to apply & register for june 5 webinar, clinical laboratory fee schedule preliminary gapfill rates: submit comments by july 1, home health quality reporting program: draft oasis-e1 instruments & manual, mental health: it’s important at every stage of life, claims, pricers, & codes, skilled nursing facility prospective payment system: patient driven payment model fy 2024 icd-10 code mappings, hcpcs public meeting — may 28–30, publications, part b drug payment limits overview, resource of health equity-related data definitions, standards, and stratification practices, from our federal partners, providers accepting champva: enroll in direct deposit now.

President Biden’s lower cost prescription drug law, the Inflation Reduction Act, is helping millions of seniors and families save money on health care costs and prescription drugs. The law took on Big Pharma to finally allow Medicare to directly negotiate with participating drug companies for the prices of covered prescription drugs, caps the cost of insulin at $35 for seniors, and makes recommended vaccines free for Medicare Part D enrollees. On May 3, 2024, the HHS Office of the Assistant Secretary for Planning and Evaluation published a new report showing that in 2023 more than 10 million people with Medicare Part D received a free vaccine thanks to the law – an increase from just 3.4 million people receiving covered vaccines in 2021.

More Information:

• Full CMS press release
• Medicare Drug Price Negotiation Program Draft Guidance (PDF) and  fact sheet (PDF)
• Updated timeline of the Inflation Reduction Act (PDF)

You may be interested in this topic from the CMS Roundup : CMS Initiates National Coverage Analysis for Implantable Heart Failure Management Device, Public Comments Open.

The Medicare Shared Savings Program will accept applications through the ACO Management System starting May 20, 2024. Apply no later than noon ET on June 17, 2024.

Accountable Care Organizations (ACOs) interested in Advance Investment Payments  (PDF) or the  ACO Primary Care Flex Model must first apply to the Shared Savings Program.

To learn more about the process,  register for the upcoming June 5, 2024, webinar on Completing Phase 1 of the Application and Avoiding Common Deficiencies.

More information: 

• Application Types & Timeline webpage
• Application Toolkit  
• Key Application Actions and Deadlines (PDF)
• Email questions to  [email protected]

CMS published  preliminary gapfill rates (ZIP) for the Clinical Laboratory Fee Schedule (CLFS). Send your comments on these rate recommendations to  [email protected] by July 1, 2024. 

Visit CLFS Annual Public Meetings for more information.

CMS posted draft Version E1 of the OASIS data set effective January 1, 2025:

• Instruments (ZIP)
• Manual (PDF)  
• OASIS Data Sets webpage
• OASIS User Manuals webpage

Mental and physical health are equally important components of overall health. For example, depression increases the risk for many types of physical health problems, particularly long-lasting conditions like  diabetes ,  heart disease , and stroke (see  CDC ). During  Mental Health Awareness Month , recommend appropriate preventive services, including:

• Alcohol misuse screening and counseling
• Annual wellness visit
• Depression screening
• Initial preventive physical exam

Medicare covers preventive services, and your patients pay nothing if you accept assignment. Find out when your patient is  eligible for these services . If you need help, contact your eligibility service provider.

• Medicare & Mental Health Coverage booklet
• Behavioral Health Integration Services (PDF) booklet
• Opioid Use Disorder Screening & Treatment webpage
• Addressing & Improving Behavioral Health webpage
• Depression (PDF) data snapshot: Learn about disparities in Medicare patients
• Preventive & screening services webpage: Get information for your patients

CMS recently issued a correction notice associated with the FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) final rule, which corrected errors in the ICD-10 mappings used to group patients into payment groups under the SNF PPS. These errors may have led to errors in payment for a limited number of SNF PPS claims. We encourage providers to recalculate HIPPS codes and adjust claims that meet the following criteria:

• Primary diagnosis listed in item I0020B of the patient assessment associated with the claim is also listed in Table 2 in the correction notice
• One of items J2300–J2330 is checked on the patient assessment associated with the claim

Tuesday, May 28 – Thursday, May 30, 2024, from 9 am – 5 pm ET

Attend a virtual public meeting for the first biannual 2024 HCPCS coding cycle. Visit HCPCS Level II Public Meetings for more information, including:

• Meeting materials

CMS published the Part B Drug Payment Limits Overview (PDF) to explain:

• Average sales price payment limit calculation
• Other Medicare Part B drug payment methodologies

CMS released a resource document (PDF) of health equity-related data definitions, standards, and stratification practices.

• CMS Framework for Health Equity
• The Path Forward: Improving Data to Advance Health Equity Solutions (PDF)

Are you a health care provider who submits claims to Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)? Enroll in direct deposit to get your claim payments by electronic funds transfer (EFT). Getting paid by EFT is convenient, but it’s also a  federal requirement .

EFT is secure, efficient, and helps safeguard Veterans’ family members’ access to benefits. 

If you haven’t already:

• Visit the VA Financial Services Center  Customer Engagement Portal
• Enroll using the Payment Account Setup web form

Your payments will be automatically deposited into a bank account. 

If you aren’t enrolled in EFT, your claims payments will be paused until you are. Make the move today.

For assistance with the webform, call 877-353-9791. 

About CHAMPVA

CHAMPVA is a health care program for qualified spouses, widows(ers), and children of eligible Veterans. Through CHAMPVA, VA shares the cost of certain health care services and supplies with eligible beneficiaries. 

• CHAMPVA – Information for Providers webpage
• U.S. Department of Veterans Affairs webpage

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View the  Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure .

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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Billing, Claims, and Appeals

• Billing Situations
• Claim Submission
• Electronic Claim Submission
• Healthcare Integrated General Ledger Accounting System (HIGLAS)
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Mandatory Claim Submission

Centers for medicare & medicaid services claims filing policy.

• For services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and non-assigned durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries. Beneficiaries should not be asked to file their own claims.
• The claim filing requirement applies to all suppliers who provide covered services to Medicare beneficiaries.
• Suppliers are not required to take assignment of Medicare benefits unless they are enrolled in the Medicare Participating Supplier Program or where CMS regulations require mandatory assignment, i.e., Medicare covered drugs.
• DME MACs monitor compliance with the Medicare claims filing requirement.
• Suppliers who do not submit Medicare claims for Medicare beneficiaries may be subject to a civil monetary penalty of up to $2,000 for each violation.
• If the supplier determines that the beneficiary has other insurance which may pay primary to Medicare, they may file a claim with the primary insurer on the beneficiary's behalf. However, suppliers are not required by law to submit claims to other payers. If the supplier receives a determination on the claim directly from the primary payer, they are responsible for submitting a claim to Medicare for secondary payment. If the beneficiary files a claim to the primary insurer, they may forward the primary payer information to the supplier to submit the Medicare Secondary Payer (MSP) claim. The supplier must submit the secondary claim to Medicare for the beneficiary in accordance with the mandatory claims filing requirements.
• If a beneficiary elects to receive an item for which there is no order, the claim must be filed with an EY modifier.

Mandatory Claim Filing Does Not Affect the Following:

• Supplier/Beneficiary Payment Arrangements – Suppliers who do not accept assignment may continue to request payment in full at the time the service is provided if the claim for this service is unassigned.
• Providing Supplier's Information on Non-assigned Claims - By not accepting assignment of Medicare benefits, suppliers are not a party to the Medicare payment transaction between Medicare and the Medicare beneficiary. The transaction is covered by the Privacy Act. MACs can only give limited information on non-assigned claims and cannot disclose payment amounts.
• Non-Covered Medicare Services - Suppliers are not required to file claims on behalf of Medicare beneficiaries for non-covered benefits or for other health insurance benefits. However, if the beneficiary (or his/her representative) believes that a service may be covered or desires a formal Medicare determination, the supplier must file a claim for that service to effectuate the beneficiary's right to a determination.
• Social Security Act, Section 1848(g)(4)
• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.3.9

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Consent to Monitoring

Warning: you are accessing an information system that may be a U.S. Government information system. If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. Users must adhere to CMS Information Security Policies, Standards, and Procedures. For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. The use of the information system establishes user's consent to any and all monitoring and recording of their activities.

Note: The information obtained from this Noridian website application is as current as possible. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval.

This warning banner provides privacy and security notices consistent with applicable federal laws, directives, and other federal guidance for accessing this Government system, which includes all devices/storage media attached to this system. This system is provided for Government authorized use only. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. At any time, and for any lawful Government purpose, the government may monitor, record, and audit your system usage and/or intercept, search and seize any communication or data transiting or stored on this system. Therefore, you have no reasonable expectation of privacy. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose.