ABA Family Legal Guide

The Rights of Older Americans

Health and Long-Term Care Benefits

Medicare

What is my share of Medicare Part B costs?

For Part B benefits, you must pay an annual deductible, which is adjusted every year. Then Medicare generally pays 80 percent of Medicare-approved amounts for covered services for the rest of the year. You pay the other 20 percent of the approved amount. There is no cap on the patient's share of the cost.

If a physician or other provider charges you more than the Medicare-approved amount, then your liability depends on whether the provider accepts assignment. Accepting assignment means that the provider agrees to accept the Medicare-approved amount as payment in full. If the provider does not accept assignment, generally you must pay for any excess charge over the Medicare-approved amount, but only up to certain limits. If you are a Medicaid recipient, then your physician must accept assignment.

The government presently sets the limit on physician's charges at 115 percent of the Medicare-approved fee schedule. Doctors who charge more than these limits may be fined, and you should get a refund from the doctor.

Here is an example of the difference accepting assignment can make. Mrs. Jones sees Dr. Brown on June 1 for medical care. She has already paid her $100 annual deductible for covered Part B medical care. Dr. Brown charges $230 for the visit. The Medicare-approved amount for such services is $200, and Medicare pays 80 percent, or $160.

If Dr. Brown accepts assignment, Mrs. Jones must pay a $40 co-payment (that is, 20 percent of the $200 approved).

If Dr. Brown does not accept assignment, Mrs. Jones must pay $40 plus the $30 excess charge. Her total payment is $70.

Note that Dr. Brown's actual charge ($230) is within 115 percent of the Medicare-approved amount ($200) and is therefore permissible.