Participating vs. Nonparticipating Medicare Providers
Short answer
Participating Original Medicare providers agree to accept assignment for all Medicare-covered services. Nonparticipating providers remain enrolled in Medicare but may accept assignment case by case.
Coverage
When a nonparticipating provider does not accept assignment, different payment and beneficiary-billing rules can apply, including Medicare’s limiting charge for many Part B services.
Not Automatic
A nonparticipating provider is not the same as a clinician who has formally opted out of Medicare and uses private contracts.
Costs And Ma
This distinction primarily affects Original Medicare. Medicare Advantage members should instead verify whether the provider is in the plan’s network and accepts the plan.
Practical Example
Two physicians can both be enrolled in Medicare, but one may participate and always take assignment while the other does not participate and may decide service by service.
Questions to verify
- Is the provider participating, nonparticipating or opted out?
- Will assignment be accepted for this service?
- Am I using Original Medicare or a Medicare Advantage network?