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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.

fizkes / Getty Images

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 Louise Norris has been a licensed health insurance agent since 2003 after graduating magna cum laude from Colorado State with a BS in psychology.

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PECOS for dummies Part I: Reassigning Benefits

• by Rocky Fenton

Are you a confused or burnt-out provider? Well just be burnt-out, because we are about to give you a step-by-step guide to reassigning your benefits through PECOS! Reassigning benefits means you can start seeing Medicare patients under a new organization, and in return be reimbursed something less dismal than most of your commercial payors fee schedules. And if you are still confused – feel free to reach out to our team and we will be more than happy to assist you!

Note: you can find all this information on the Noridian website and on YouTube. I provided both links below.

Enrollment: PECOS Reassignment of Benefits through Individual Provider

Source: https://med.noridianmedicare.com/

Source Video: https://www.youtube.com/watch?v=GmwKposslao

• Log in to PECOS
• Select “My Associates”
• On the “My associates” page select “View Enrollments”
• Scroll to the “Existing Enrollments” section – Select “View/Manage Reassignments” – “Manage Reassignments”
• Select “Add a new reassignment”
• Answer if entity or individual receiving benefits is enrolled in Medicare (Yes typically)
• “Additional Changes” dialogue box should show – select “no” unless changing other information
• Select “Start Application”
• Navigate to “Reassignment” topic – Click “Begin Submission”
• “Filter Reassignment of Benefits” dialogue box should show – Select “Add Information”
• Select whether benefits will be reassigned to “Individual” or “Organization” – Select “Next Page”
• Effective Date of Information – ** cannot be more than 60 days in future from when application is received, or application will be returned
• Legal business name – should match exactly as it appears on IRS documentation
• Fill out remaining TIN and NPI information – Select “Next Page”
• Enter Medicare ID number, including all preceding numbers and letters. If it is a new organization, enter “Pending” and select next page
• “Reassignment Practice Location Choice” dialogue box should appear. Select what the primary (and secondary if necessary) practice location you intend the provider to practice. Enter the location address and continue
• Verify the information and select “Next Topic”. Or if adding multiple reassignments to multiple TINs – Select “Add information” at the top and repeat the previous steps
• “Contact Person” dialogue box should appear. Review and add any contacts. Select “Review Complete”
• Check the “Error/Warning” tab and review anything that needs attention. Click “Begin Submission” when complete
•  Signature method – If provider is completing the application select “Electronic”. If someone is working on behalf of the provider – select “E-Sign” and instructions will be sent to the provider’s email that you enter on the following prompt. Select “Next Page”
• The following page will require documentation uploaded. “Authorization Statements” will be E-Signed by the provider. Once this has been completed – select Complete Submission
• Application status can be monitored from the My Enrollments Page
• If the application is returned for correction
• 30 days are allotted for the corrections to be made
•  All signatures must be submitted for processing to begin on the application
•  Upload the required documents as a PDF or TIFF

Enrollment: PECOS Reassignment of Provider through Organizations Enrollment

Source Video: https://www.youtube.com/watch?v=x-rIn0NQRWc

• Select “View Enrollments”
• Select “View/Manage” Reassignments at the bottom of the dialogue box
• Select “Manage Reassignments”
• Select “Add reassignment of benefits where someone is reassigning benefits to the group or organization”
• “Additional Changes” dialogue box should show – select “No, I only need to make Reassignment Updates” if you do not wish to make any other changes
• Select “Start Application” and navigate to the “Reassignment” topic
• “Filter Reassignment of Benefits dialogue box will show – select “Add Information”
• “Accept Reassignment” dialogue box should show – fill out the requested information for who will be accepting reassignment
• “Medicare Identification Numbers” dialogue box should show – enter Medicare Identification Number. If the organization has more than one ID – select “Add More” and fill out the remaining IDs
• “Practice Location Address…” dialogue box should show – select the Primary location where services are rendered. This section can also be left blank
• *Note – Multiple Reassignment additions can be made on one 855B enrollment, however it is recommended to limit this to 25 reassignments to be added or deleted to decrease processing time
• “Contact Person” dialogue box should show – select “add information” and complete the main contact’s information and click “Save”
• “Enrollment Submission” dialogue box should show – Review any warning / error checks if needed. Select “Begin Submission” on the “Error/Warning Check” tab
• A Signature method prompt will appear – If the provider is signing off, select “Electronic” and select “Next Page”
• If you are the provider and are E-Signing, review the terms and conditions at the bottom and check the “Yes” box. If you are not the provider, you can enter the providers email address and instructions will be sent to them for an E-signature.
• Select the “Complete Submission” button.

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Use the New Form CMS-855R for Reassignment of Medicare Benefits

The Centers for Medicare and Medicaid Services (CMS) is releasing a revised Form CMS-855R for physicians and non-physicians practitioners to reassign their Medicare benefits. There will be a two-month transition window, during which providers can use the old form, last updated in 2016, or the new form, which is set to be published by CMS any day now. Beginning May 1, 2020, only the updated form will be accepted.

Form CMS-855R is used by providers to reassign their right to bill the Medicare program and receive Medicare Part B payments to an eligible individual, clinic/group practice, or other health care organization. The individual or group to whom the benefits are reassigned then submits claims and receives payment on the provider’s behalf. Form CMS-855-R also is used to change or terminate a reassignment, and with the revised form, providers will be able to identify a secondary practice address or select “Change of Reassignment Information” as the reason for submitting the form.

In order for a reassignment to take effect, both the individual provider and the eligible organization/group must be currently enrolled or concurrently enrolling in the Medicare program. According to Medicare, the organization/group accepting the reassignment usually submits CMS-855R to initiate the change; however, either the organization/group or the individual practitioner may submit the form when terminating a current reassignment.

In addition to using form CMS-855R, all of these requests also can be made using Medicare’s Internet-based Provider Enrollment, Chain and Ownership System (PECOS).

For more information about the Medicare reassignment process, as well as Medicare enrollment in general, visit the Medicare Provider-Supplier Enrollment page of CMS.gov. For more information about online enrollment through PECOS, visit the Internet-based PECOS page. Finally, since the new Form CMS-855R has not yet been published, check back regularly to the Enrollment Applications page, which has links to all current enrollment forms.

—  All rights reserved. For use or reprint in your blog, website, or publication, please contact us at [email protected] .

• Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

• February 21, 2020
• Medicare , Provider Enrollment

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• CMS Updates Benefits Reassignment Application, CMS...

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CMS Updates Benefits Reassignment Application, CMS-855R

• Mark Complete

The Centers for Medicare and Medicaid Services is updating their reassignment-of-benefits application, CMS-855R  to make the primary practice location an option. They expect the new version to be available by the end of the year. Beginning Jan. 1, 2017, CMS will only accept the new version. Learn more about enrolling in or editing your existing Medicare application  on the CMS website.

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The Sydney Morning Herald

Health department to consider funding gender-affirming surgery under medicare, by natassia chrysanthos, save articles for later.

Add articles to your saved list and come back to them any time.

Gender-affirming procedures such as chest surgery and genital reconfiguration would be subsidised by Medicare under a push to improve mental health and quality of life for transgender people.

The federal health department will consider an application from the Australian Society of Plastic Surgeons that seeks to establish 21 Medicare items for gender-affirming surgeries for people who have gender incongruence, in which a person’s experience of gender does not align with how they were born.

The application said gender-affirming surgery is already being performed in Australia but the system is fragmented and can have high out-of-pocket costs. Credit: Eddie Jim

The application to the Medical Services Advisory Committee says gender-affirming surgery – a catch-all term for procedures that align a person’s body with their gender identity – is already being performed in Australia but that the system is fragmented and can have high out-of-pocket costs.

It estimated there would be 64,101 transgender people who were born male and 64,044 transgender people who were born female who could be candidates for the procedures in Australia.

The procedures pitched for Medicare coverage include feminising chest surgery, which may involve inserting prosthetics or fat grafts, and masculinising chest surgery, which may or may not require repositioning nipples.

There are also proposed Medicare items for genital reconfiguration surgery, which could involve removing genitals or constructing a neo-penis or neo-vagina, as well as feminising or masculinising facial surgery and voice surgery.

The proposal, which will be considered at a meeting next month, suggests the Medicare rebates be limited to adults between 18 and 50 years old.

“Some medical interventions for gender affirmation are irreversible, may be associated with a risk of adverse effects, involve complex surgical procedures or have consequences on reproductive options after treatment,” it says.

People seeking gender-affirming surgeries currently deal with a mix of non-specific Medicare items or fund their treatment themselves, and they might pay more than $20,000 or go overseas to access surgery.

“The current funding arrangements for surgical procedures is highly fragmented,” the application says.

It says current Medicare item descriptors are a “poor fit” for gender-affirming surgeries that cause anxiety to doctors who used them, in case they are not appropriate, while other interventions are not subsidised when used for gender-affirming purposes.

“Despite the lack of [Medicare] funding, these procedures are well-established for the purposes of gender affirmation,” it says.

The fee list, to be based on existing rebates for similar procedures, is still being developed. The application gives examples suggesting a $1335.70 rebate for masculinising chest surgery, and that voice surgery can be covered by a $621.20 or $1006.55 rebate, depending on the type of procedure.

But the overall cost per patient would vary substantially depending on which procedures are performed.

The Australian Society of Plastic Surgeons declined a request for an interview. However, its application says legitimised and universal access to gender-affirming medical interventions is an important way of improving the mental health of transgender people and those with gender incongruence.

Australian studies have shown such people report higher rates of psychiatric conditions, suicidal ideation and suicide attempts than the general population. Other research shows gender diverse people report their quality of life significantly improved after undergoing gender-affirming surgery.

A 2021 petition for public funding of gender-affirming surgery was backed by almost 150,000 people, but then-health minister Greg Hunt in his response said no specific application had been made to list items through the Medicare Benefits Schedule.

The Australian Society of Plastic Surgeons wrote that its new application “directly addresses the gap identified by then Minister Hunt as a means to progress making gender-affirming services eligible for a Medicare benefit”.

Royal Australian College of GPs vice president Bruce Willett said the Medicare advisory committee had a vital role in weighing up evidence to carefully consider the application. “Patients should be able to access the care and treatments they need, regardless of income or postcode,” he said.

“There is next to no access to gender-affirming surgeries within the public system. Evidence suggests surgery can relieve gender dysphoria, improve patient mental health and quality of life, and potentially save lives. No one should be left behind, and that is exactly what can happen when people come up against long waiting lists for care.”

A Health Department spokesperson said the application would be considered by a sub-committee in December, before a likely assessment by the full advisory committee next year.

”The Australian government is committed to supporting Australians to access high-quality health care,” the spokesperson said. “There is a range of [Medicare] items that could be used at various stages of the gender-affirming process, including GP and specialist consultation items. [Medicare] rebates are also available for some surgical procedures which may be performed during gender affirmation process.“

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U.S. Dept. of Health & Human Services

Processing the CMS-855R Medicare Enrollment Application - Reassignment of Benefits

Guidance for providers and suppliers in completing the CMS-855R application and MACs in processing the CMS-855R application

Download the Guidance Document

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

Issue Date: January 01, 2020

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the [email protected] .

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.