For Medicare-covered services, you must first pay the Medicare Part B annual deductible, which is $183 in 2018. After you have met your deductible, you pay a Part B coinsurance for Medicare-covered services. For doctors’ visits (including visits to outpatient mental health care providers) you generally pay 20% of the Medicare-approved amount for care you receive. This is also called a 20% coinsurance.

However, you may have to pay more depending on what type of doctor you see and whether your doctor takes Medicare assignment. A doctor who takes Medicare assignment agrees to accept the Medicare-approved amount as full payment. In general, there are three categories of Original Medicare doctors:

  1. Participating doctors are doctors who accept Medicare and always take assignment. Participating doctors are required to submit a bill (medical claim) to Medicare for care you receive. Medicare will process the bill and pay your doctor directly for care that he/she provided to you.

    • If you see a participating doctor, you are only responsible for paying a 20% coinsurance for Medicare-covered services. Most doctors who treat patients with Medicare are participating doctors.

  2. Non-participating doctors are doctors who don’t routinely take assignment. Like participating doctors, non-participating doctors are required to submit a bill (medical claim) to Medicare for care you receive. However, you generally need to pay non-participating doctors directly for the full cost of care you receive. Medicare will process the bill and reimburse you directly for Medicare’s share of the cost of care you receive (generally 80% of Medicare’s approved amount for most medical services).

    • If you see a non-participating doctor, you may pay up to 15% of the Medicare-approved amount for non-participating providers, on top of a 20% coinsurance for care you receive. This extra 15% is called the limiting charge. Altogether, that means you may be responsible for paying 35% (20% coinsurance +15% limiting charge) of Medicare’s approved amount for care provided by non-participating doctors. However, keep in mind that some states may have stricter limits on what doctors may charge you. For example, New York’s limiting charge is lower than the 15% limiting charge and is set at 5%. You can call your State Health Insurance Assistance Program (SHIP) to find out more.

    • Note also that limiting charge laws do not apply to certain health care providers, such as durable medical equipment suppliers. If these providers (e.g., suppliers) don’t accept assignment, they aren’t limited in how much they can charge you.

  3. Opt-out doctors are doctors who have formally opted out of the Medicare program. Opt-out doctors can charge their Medicare patients whatever they want. These doctors do not submit any bill (medical claims) to Medicare and are not subject to the Medicare law that limits the amount doctors may charge patients.

    • If you see an opt-out doctor, you pay the entire cost of your care (except in emergencies). The doctor should have you sign a private contract that states that you understand you are responsible for the full cost of the services. Medicare will not pay for any of the cost of services you receive from an opt-out doctor.

    • Note that psychiatrists are more likely than any other type of provider to opt-out of Medicare.

Be sure to always ask your doctor if he/she accepts Medicare before you get care. In addition, you can learn whether your doctor accepts Medicare and takes assignment by going online and visiting Medicare’s Physician Compare tool.