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COLUMN: Understanding Medicare assignment

William C. Lane, Ph.D., Special to the Daily Sentinel
Posted 3/3/23

The winter Medicare Advantage Open Enrollment Period ends on March 31. Many people forget that the fall Open Enrollment Period is not the only time you can make some changes.

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COLUMN: Understanding Medicare assignment


The winter Medicare Advantage Open Enrollment Period ends on March 31.

Many people forget that the fall Open Enrollment Period is not the only time you can make some changes to your Medicare coverage. During the current winter period, you can change from one Medicare Advantage plan to another or leave your current Advantage plan and enroll in Original Medicare with a Part D drug plan.

The one thing you cannot do is switch from Original Medicare to a Medicare Advantage plan. If you would like to make a change in your coverage, contact your HIICAP office.

Coverage of Insulin Under Medicare. As discussed last month, there is now a cap of $35, without any deductible, on the monthly cost of insulin covered by Part D drug plans. Drug plans have until the end March to implement this change. If you paid more than the $35 cap for insulin during January or February, your plan must reimburse you for any amount you paid above the cap within 30 days. Contact your plan directly to obtain a refund. If you have any problems in obtaining this refund, contact your county HIICAP office for assistance.

Free COVID-19 Tests are Still Available. While we would like to think that the dangers of COVID-19 are in the past, people are still becoming infected and even being hospitalized all across New York. You can still order four free COVID-19 test kits by going to or by calling 1-800-232-0233 (TTY 1-888-720-7489). On the website you can also find a listing — with pictures of each test — of the extended expiration dates of all the various home test kits. So, don’t discard your current tests without checking the website.

What Does Medicare Pay? In this article we are going to focus on Medicare Part B. Part A will be covered in a future article. First, before beginning our discussion there are three terms that need to be defined:

Deductible. The deductible is the amount you pay for medical services, either out-of-pocket or through coinsurance, before Medicare begins to pay for your care. This year the annual Part B deductible is $226, a decrease of $7 from 2022.

Coinsurance. Coinsurance is the percentage of the cost you must pay after you have met your deductible for the year.

Copay. A copayment is a set rate that you pay for doctor visits, prescription drugs or other care.

Once you have met your Part B deductible for the year, Medicare will pay for 80% of “covered medically necessary services.” This means that you are responsible for the remaining 20% or coinsurance portion of the cost of your care.

Medicare Assignment. According the Centers for Medicare and Medicaid Services (CMS) approximately 93% of all physicians accept Medicare. Of these, 98% accept Medicare assignment and are known as participating providers.

According to CMS, Medicare assignment “means that your doctor, provider or supplier agrees to accept the Medicare-approved amount as full payment for covered services.” Your provider will only charge you the appropriate deductible and coinsurance amount. If you have a Medigap policy this will, in most cases, cover the coinsurance charges and you will only be responsible for a relatively small copay.

Also, by accepting assignment your provider will submit their claim directly to Medicare (you cannot be charged by them for submitting this claim) and you will not be billed until after Medicare has approved the charges.

Non-Participating Providers. Non-participating providers have agreed to accept Medicare but not Medicare assignment. These providers may charge up to 15% above the Medicare approved amount for a covered service. This extra payment is called a limiting charge and is based on the Medicare approved amount for the service and not on the amount the provider originally charged. So, you will be responsible for the 20% coinsurance plus up to an additional 15% in provider charges. Your coinsurance may or may not cover some or all of this additional charge.

Opt-Out Providers. Opt-out providers represent the very small percentage of providers who choose not to work with Medicare insurance. With these providers, Medicare will not pay for any covered items or services provided with the exception of emergency department or urgent need care. Patients set up mutually agreed upon fees and payments under a private contract. Medigap policies are designed to work only with providers who accept Medicare and will not cover any charges from opt-out providers.

The Oneida County HIICAP Office is continuing to provide counseling services and in-person scheduling by phone as they have throughout the pandemic. If you would like to do a HIICAP counseling session over the phone or schedule an appointment at one of the two in-person locations call 315-798-5456 and select #2 from the choice list. In most cases you will be asked to leave your contact information on a voice mail and a staff member will return your call within 72 hours (3 business days). Counselors are available at the following locations:

Copper City Community Connection, 305 E. Locust St., Rome will offer counseling session from 9 a.m. to 3 p.m. Thursday only. The HIICAP program will also be scheduling at Copper City.

North Utica Senior Citizens Center, 50 Riverside Drive, Utica. Hours have been expanded at this site. Appointments will now be accepted on Monday, Wednesday and Friday from 9 a.m. to 3 p.m. Sessions are expected to run 45 minutes. Call the HIICAP office at 315-798-5456, selecting option 2 to schedule an appointment.

Contacting HIICAP Programs in Other Counties. Here is the contact information for HIICAP programs in several counties that border Oneida County. To reach the Madison County HIICAP program call 315-697-5700 and ask to speak to a HIICAP counselor. For Herkimer County, call Catholic Charities of Herkimer County at 315-894-9917. For Lewis County call 315-376-5013 and select #2 from the choice list.

Dr. William Lane is the owner of William Lane Associates, a gerontological consulting firm located in Homer, NY. He writes a monthly column on HIICAP related issues for the OFA. Dr. Lane does not sell insurance, work for any insurance company or recommend any insurance products.


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