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What You Pay Your Doctor Under Medicare Depends

Last Updated: 11/3/11

If you have original Medicare, the doctor you visit can make a difference in how much you have to pay. While you can go to any doctor who accepts Medicare payments, if the doctor does not "accept assignment," you can end up paying a lot more.  (This does not apply to beneficiaries who are in Medicare Advantage, or managed care, plans.)

Medicare Part B recipients must satisfy an annual deductible. Once the deductible has been met, Medicare pays 80 percent of what Medicare considers a "reasonable charge" for the item or service. The beneficiary is responsible for the other 20 percent.

However, in most cases what Medicare calls a "reasonable charge" is less than what a doctor or other medical provider normally charges for a service. Whether a Medicare beneficiary must pay part of the difference between the Medicare-approved charge and the provider's normal charge depends on whether or not the provider has agreed to participate in the Medicare program.

If your doctor participates in Medicare it means that the doctor "accepts assignment." In other words, the doctor agrees that the total charge for the covered service will be the amount approved by Medicare. Medicare then pays the provider 80 percent of its approved amount, after subtracting any part of your annual deductible that has not already been met. The provider then charges you the remaining 20 percent of the approved "reasonable" charge, plus any part of the deductible that has not been satisfied.

If your doctor does not participate in Medicare and does not accept assignment, the rules are different. Non-participating doctors can charge 20 percent of the approved amount plus up to an additional 15 percent more than the Medicare-approved amount. Non-participating doctors can also charge you for the care upfront and request that you bill Medicare, while doctors who accept assignment cannot.

For more information about Medicare, click here.

To discuss elder law issues with an attorney, please email the Elder Law Center or call 630-844-0065. The Elder Law Center is located in Aurora, IL, Kane County, in the Chicago Western Suburbs.