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What is Medicare Reimbursement and Does It Cover the Full Cost of My Care?

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Medicare reimbursement can mean a couple of different things.

  • It can refer to the Medicare payments that hospitals, doctors, and other health-care providers and suppliers receive in return for Medicare services.
  • It can also mean reimbursement you may receive after filing a Medicare claim.

Does Medicare reimbursement cover the full cost of care?

When you receive care from a provider who accepts Medicare assignment, that means the provider agrees to accept the Medicare-approved amount. The Medicare provider (like a doctor or hospital) can’t charge you more. You may have to pay the Medicare deductible amount or a coinsurance or copayment. You probably won’t have to file a claim for Medicare reimbursement.

The provider, on the other hand, might have to get Medicare reimbursement to cover the cost of your care.

Medicare reimbursement and providers who don’t accept Medicare assignment

If a provider doesn’t accept Medicare assignment, he or she might be legally allowed to charge you more than the Medicare-approved amount – up to 15% more. Medicare reimbursement to the provider is usually 95% of the Medicare rate in this case.

The provider might require you to pay your cost-sharing amount at the time of service. You normally don’t have to pay the entire covered amount and then seek Medicare reimbursement. If you do have to pay the entire amount up front, you can file a claim for Medicare reimbursement.

Medicare opt-out providers do not agree to accept Medicare rates or reimbursements for any services, for any patients with Medicare. They are prohibited from billing Medicare. Typically, Medicare reimbursement is $0 to a Medicare opt-out provider or the patient for services, even if the services related to the care would otherwise have been Medicare-covered services. You will have to pay a Medicare opt-out provider’s charge and usually forego Medicare reimbursement.

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