Original Medicare - What You Should Consider When Searching For Outpatient Services

When using Original Medicare, some things to consider and understand before receiving outpatient services:

  • You will need to satisfy (fully pay) your Part B annual deductible first before Original Medicare benefits kick in for Part B services. The Part B deductible may increase from year to year, and your annual deductible will reset each year, starting fresh on January 1st.

  • There are three different types of providers:

    • A "participating provider” is a provider that accepts Medicare and always takes assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. So in order to pay the least amount for outpatient services, you should go to a participating provider whenever possible. This type of provider (a participating provider) is required to submit a bill (file a claim) to Medicare for the care you receive from them. If you go to a participating provider then you are responsible for paying 20% coinsurance for Medicare covered services.

    •  A "Non-participating" provider accepts Medicare, but does not agree to take assignment in every case (however they may take assignment on a case by case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for your healthcare services as full payment. Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of the services you receive (known as the limiting charge). This means that you are responsible for a total of up to 35% (20% coinsurance +15% limiting charge) of Medicare’s approved amount for covered services at a non-participating provider.

    • An “Opt-out provider" does not accept Medicare at all and has signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You will be responsible for the entire cost of your care!

Bottom Line: Before you get service, make sure to ask you provider if they are participating, non-participating, or opt-out so you don’t have some unpleasant surprises when it comes to paying your bill!