C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 424—CONDITIONS FOR MEDICARE PAYMENT › Subpart D—To Whom Payment Is Ordinarily Made

42 C.F.R. § 424.55

Payment to the supplier

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(a) Medicare pays the supplier for covered services if the beneficiary (or the person authorized to request payment on the beneficiary's behalf) assigns the claim to the supplier and the supplier accepts assignment.

(b) In accepting assignment, the supplier agrees to the following:

(1) To accept, as full charge for the service, the amount approved by the carrier as the basis for determining the Medicare Part B payment (the reasonable charge or the lesser of the fee schedule amount and the actual charge).

(2) To limit charges to the beneficiary or any other source as follows:

(i) To collect nothing for those services for which Medicare pays 100 percent of the Medicare approved amount.

(ii) To collect only the difference between the Medicare approved amount and the Medicare Part B payment (for example, the amount of any reduction in incurred expenses under § 410.155(c), any applicable deductible amount, and any applicable coinsurance amount) for services for which Medicare pays less than 100 percent of the approved amount.

(3) Not to charge the beneficiary when Medicare paid for services determined to be “not reasonable or necessary” if—

(i) The beneficiary was without fault in the overpayment; and

(ii) The determination that the payment was incorrect was made by the carrier after the third year following the year in which the carrier sent notice to the beneficiary that it approved the payment.

(c) Exception. In situations when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, the beneficiary (or the person authorized to request payment on the beneficiary's behalf) is not required to assign the claim to the supplier in order for an assignment to be effective.

(d) For purposes of claims for services submitted by an MDPP supplier (as defined at § 410.79(b) of this chapter), Medicare deems such claims to have been assigned by the beneficiary (or the person authorized to request payment on the beneficiary's behalf) and the assignment accepted by the MDPP supplier.

[53 FR 6634, Mar. 2, 1988, as amended at 63 FR 20130, Apr. 23, 1998; 69 FR 66426, Nov. 15, 2004; 82 FR 53364, Nov. 15, 2017]
Notes of Decisions
Cited in 13 cases (4 in the last 5 years), 1998–2026 · leading case: MacKenzie Med. Supply, Inc. v. Leavitt, 506 F.3d 341 (4th Cir. 2007).
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MacKenzie Med. Supply, Inc. v. Leavitt, 506 F.3d 341 (4th Cir. 2007). “§ 1395u(b)(3)(B); 42 C.F.R. §§ 424.55 , 802. During the relevant time period, certain carriers, called DME Regional Carriers (DME Regional Carriers), processed DME claims within designated regions of the country.”
Lipstein v. UnitedHealth Grp., 296 F.R.D. 279 (D.N.J. 2013). “at 8, citing 42 C.F.R. § 424.55 .) In the case of a provider who does not accept Medicare, however, no similar law exists to cap the amount of reimbursement for the provider.”
United States ex rel. Phalp v. Lincare Holdings, Inc., 116 F. Supp. 3d 1326 (S.D. Fla. 2015). “” 42 C.F.R. § 424.55 (a).' Consequently, a beneficiary need not sign every single claim or individually assign each one.”
Tap Pharm. v. U.S. Dep't of Health & Human Servs. Health Care Fin. Admin. Palmetto Gov't Benefits Administrators, 163 F.3d 199 (4th Cir. 1998). “The parties expressly subject to the Act are beneficiaries and their assigns, see 42 C.F.R. § 424.55 , whose statutorily-protected interests are in the direct receipt and provision of “reasonable and necessary” medical services, 42 U.”
Troy Olhausen v. Arriva Med., LLC, 124 F.4th 851 (11th Cir. 2024). “” See 42 C.F.R. § 424.55 (a). But with- out assignments, Medicare pays the beneficiary instead.”
Courtney v. Choplin, 195 F. Supp. 2d 649 (D.N.J. 2002). “1395u(b)(3)(B)(ii); 42 C.F.R. 424.55(b); see also, Manakee Professional Medical Transfer Service, Inc.”
Maximum Comfort, Inc. v. Thompson, 323 F. Supp. 2d 1060 (E.D. Cal. 2004). “§ 1395u(b)(3)(B)(ii); 42 C.F.R. § 424.55 . 5 . Brenda Hayes was the designated lead Medicare beneficiary in the Administrative Law Judge's review of this group of claims audit, referred to as the 'Hayes group’ claims throughout the record.”
Aaro Med. Supplies, Inc. v. Dept. of Revenue, 132 P.3d 1143 (Wash. Ct. App. 2006). “" [3] 42 C.F.R. § 424.55 (b)(1)-(2)(ii). *1147 For durable medical equipment, such as the products sold here, Medicare pays 80 percent and the beneficiaries co-pay the re-maining 20 percent.”
Gen. Med., P.C. v. Sec'y of the U.S. Dep't of Health & Human Servs. (E.D. Mich. 2026). · cites it 2× “See 42 C.F.R. § 424.55 . General Medicine then submitted claims for payment directly to Medicare, and Medicare paid General Medicine directly for those services.”
Gen. Med., P.C. v. Dep't of Health & Human Servs., Sec'y of (E.D. Mich. 2022). “See 42 C.F.R. § 424.55 . General Medicine then submits claims for payment directly to Medicare, and Medicare pays General Medicine directly for those services.”
Olhausen v. Arriva Med., LLC (S.D. Fla. 2025). “See 42 C.F.R. § 424.55 (a) (“Medicare pays the supplier for covered services if the beneficiary (or the person authorized to request payment on the beneficiary’s behalf) assigns the claim to the supplier and the supplier accepts assignment.”
Aaro Med. Supplies, Inc. v. Dep't of Revenue, 132 Wash. App. 709 (Wash. Ct. App. 2006). “” 3 42 C.F.R. § 424.55 (b)(1)--(2)(ii). For durable medical equipment, such as the products sold here, Medicare pays 80 percent and the beneficiaries co-pay the remaining 20 percent.”
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— 42 C.F.R. § 424.55(b) — 1 case
Courtney v. Choplin, 195 F. Supp. 2d 649 (D.N.J. 2002). “1395u(b)(3)(B)(ii); 42 C.F.R. 424.55(b); see also, Manakee Professional Medical Transfer Service, Inc.”
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