Medicare-Approved Amount

by David Bynon, last updated

What is a Medicare-Approved Amount?

A Medicare-approved amount is what Medicare will pay for a covered service. Healthcare providers that agree to Medicare assignment accept the approved amount without excess charges.1Medicare.gov, “Lower costs with assignment”, Accessed September 29, 2021

Key Takeaways

  • Medicare-approved amounts are what Medicare will pay a doctor or other healthcare provider for an approved healthcare service.
  • Services not covered by Medicare Part A or Part B are the beneficiary’s responsibility.
  • If a doctor does not accept Medicare assignment, they may add Part B excess charges, which the beneficiary must pay.
  • Medicare Part B has no maximum coverage as long as services are medically necessary.
  • Medicare Part A has a coverage limit per benefit period.
  • Medicare Advantage and Medicare Part D have varying approved amounts depending on the plan.

What Does Medicare-Approved Amount Mean?

A Medicare-approved amount is what the government has agreed to pay healthcare providers for a medical service. Healthcare providers that accept Medicare assignments will take the Medicare-approved amount as payment for the medical services a beneficiary requires. If the service is not fully covered by Medicare then the beneficiary owes the amount that is leftover.1Medicare.gov, “Lower costs with assignment”, Accessed September 29, 2021

For example, after paying the annual deductible for Medicare Part B coverage then Medicare will reimburse the beneficiary’s doctor for 80 percent of the approved services. Beneficiaries are responsible for paying the remaining 20 percent.2Medicare.gov, Medicare costs at a glance, Accessed September 29, 2021

Some healthcare providers do not accept Medicare assignment. These healthcare providers can add up to 15 percent over the Medicare-approved amount. To avoid these excess charges, check with a healthcare provider’s office to see if they accept Medicare assignment.1Medicare.gov, “Lower costs with assignment”, Accessed September 29, 2021

Is There a Maximum Amount Medicare Will Pay?

The maximum amount Medicare will pay all depends on the type of coverage. For outpatient care like check-ups and lab work, there is no real limit to the amount Medicare Part B will pay. As long as the service is covered by Medicare, proven medically necessary, and the Part B deductible has been met, Part B will provide coverage.2Medicare.gov, “Medicare costs at a glance”, Accessed September 29, 2021

Inpatient care services at hospitals and nursing facilities have limits under Medicare Part A. When beneficiaries are admitted into a hospital, they start a benefit period that lasts 90 days. Once the deductible has been met during this benefit period, Part A will begin providing complete coverage for the first 60 days.2Medicare.gov, “Medicare costs at a glance”, Accessed September 29, 2021

If a beneficiary has a Medicare Advantage plan or Medicare Part D prescription drug plan, then the amount of coverage depends on their plan. These factors include their plan’s deductibles, copayments, and/or coinsurances for covered services.2Medicare.gov, “Medicare costs at a glance”, Accessed September 29, 2021

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