Medicare Excess Charges: Check Assignment Before a $45 Fee

A Medicare Part B excess charge is an extra fee a provider who does not accept assignment may add on top of the Medicare-approved amount, capped at 15% under the limiting charge rule. You, the beneficiary, are usually the one who owes that difference. Choosing providers who accept assignment, or carrying a Medigap plan that covers excess charges, removes most of that risk.

TL;DR:

• Nonparticipating providers may bill up to 15% above Medicare’s approved amount; opted out providers have no Medicare billing cap and require a private contract.
• For a $300 procedure, the excess charge can reach $45 after $60 in coinsurance, and it does not count toward the Part B deductible.
• Eight states restrict or ban excess charges within their borders; residents can still face them when receiving care elsewhere while traveling.
• Medigap Plans F and G cover excess charges, but Plan F is limited to people eligible for Medicare before January 1, 2020.
• Confirm assignment for the specific service before each visit, because a nonparticipating provider may accept Medicare’s approved amount on one claim but not another.

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Table of Contents

• How provider payment status determines your excess charge risk
• How much can an excess charge actually cost you?
• How often do beneficiaries actually run into excess charges?
• Which states limit or ban Part B excess charges?
• Does Medigap cover Part B excess charges?
• What to do before, during, and after a visit to avoid excess charges
• How a licensed broker checks provider assignment and Medigap fit
• Is paying more for Medigap worth it just to avoid excess charges?
• Get help comparing Medigap options and checking provider status
• FAQ
• Sources

How provider payment status determines your excess charge risk

Three provider categories decide what you can be billed. A provider who accepts assignment agrees to take the Medicare-approved amount as full payment, so you owe only your deductible and coinsurance share. A provider who has formally opted out of Medicare has no billing ceiling at all and you pay privately under a contract you sign in advance.

• Participating providers bill Medicare directly and you never see the excess charge issue.
• Non-participating providers may ask you to pay the full bill upfront, then you file for partial reimbursement yourself.
• Opted-out providers fall outside Medicare’s fee schedule entirely, so no limiting charge applies.

Some non-participating providers choose to accept the Medicare-approved amount on individual claims even though they are not obligated to, according to Medicare’s explanation of provider billing status. That is why checking assignment status per visit, not just per provider, matters.

How much can an excess charge actually cost you?

The limiting charge caps a non-participating provider’s bill at 15% above the Medicare-approved amount, and that 15% is calculated on Medicare’s fee schedule, not the provider’s own list price.

The limiting charge can add a small percentage up to but not exceeding 15% to a Medicare-approved service, and that amount sits outside your usual deductible and coinsurance math, per Medicare’s cost guidance. Say an office visit has a Medicare-approved amount of $100. A non-participating provider can charge up to $115. On a $300 outpatient procedure, the math scales the same way: a $345 billed amount means $60 coinsurance plus $45 in excess charges, or $105 instead of $60.

Excess charges do not count toward your Part B deductible and are added after your 20% coinsurance is calculated, which is what makes them feel like a separate, unpredictable layer of cost.

How often do beneficiaries actually run into excess charges?

Most routine care comes from providers who accept assignment, since the vast majority of physicians stay in Medicare’s participating network. Non-participation and opt-out rates vary by specialty and tend to concentrate among certain practice types rather than spreading evenly across all of medicine, a pattern KFF has tracked over time.

• Psychiatrists and some specialists opt out at higher rates than primary care physicians.
• Urban areas with more provider competition sometimes see different participation patterns than rural areas with fewer options.
• You can check a specific provider’s status before an appointment using Medicare’s provider lookup tools.

Geographic variability means a provider’s assignment status in one city tells you nothing about a different provider in another state, so verifying before each new relationship is worth the few minutes it takes.

Which states limit or ban Part B excess charges?

Some states restrict or prohibit Part B excess charges for services delivered within their borders, including Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont, according to Healthline’s summary of state protections.

• These protections apply to care received in that state, not to your state of residence.
• Traveling out of state for a procedure can expose you to excess charges even if your home state bans them.
• State insurance department factsheets and Medicare’s provider lookup are the fastest ways to confirm coverage before you travel for care.

Does Medigap cover Part B excess charges?

Two Medigap plans, F and G, cover Part B excess charges under Medicare’s standardized benefit structure, according to Medicare’s plan comparison page. Plan F is only available to people who became eligible for Medicare before January 1, 2020, so most new enrollees can only choose Plan G for this protection.

• Plan G carries a higher monthly premium than plans without excess charge coverage, but it eliminates the unpredictability described above.
• Plan F offers slightly broader coverage overall but is closed to anyone newly eligible for Medicare.
• Comparing the standardized benefits chart side by side shows exactly what each lettered plan covers before you commit to a premium.

The trade-off is straightforward: a higher fixed premium buys you protection against a cost that is otherwise impossible to predict in advance.

What to do before, during, and after a visit to avoid excess charges

A few habits catch most excess charges before they happen, and the rest can still be recovered after the fact by following this Medicare Special Enrollment Periods (SEP) checklist.

1. Before scheduling, ask the provider’s office directly: “Do you accept Medicare assignment for this service?” and request a written cost estimate.
2. At check-in, confirm the same answer with front-desk staff and note who you spoke with and when.
3. After the visit, request an itemized receipt that separates the Medicare-approved amount from any additional charge.
4. If a non-participating provider does not bill Medicare for you, file the claim yourself using the receipts you collected.
5. If you believe you were billed incorrectly or the limiting charge was exceeded, you can appeal through Medicare’s standard process or contact your State Health Insurance Assistance Program (SHIP) for free help.

Pro Tip: Keep every receipt, quote, and the name of whoever confirmed assignment status in one folder. It turns a dispute from a guessing game into a paper-backed claim.

How a licensed broker checks provider assignment and Medigap fit

A broker who works with Medicare day to day can shorten this whole process. We check a provider’s assignment status before you commit to a specialist, compare Medigap Plan G and Plan N quotes side by side, and review your coverage every year as your health needs or provider network changes.

• We verify whether a specific provider accepts assignment before you schedule.
• We run personalized Medigap Plan G and Plan N quotes based on your location and health needs.
• We handle annual plan reviews so a new excess-charge risk does not sneak up on you.
• We assist with claims and appeals if a billing dispute comes up after a visit.

When we review a provider for a client, we ask the same questions you would: do they accept assignment, have they opted out, and does their billing pattern match what the practice told you on the phone.

Is paying more for Medigap worth it just to avoid excess charges?

Excess charges are not an everyday expense for most Medicare beneficiaries, since most providers accept assignment. But when they hit, they hit without warning, and the math above shows how fast a routine visit turns into a bigger bill than expected.

If you regularly see specialists, travel between states for care, or simply want one less unpredictable line item, Plan G’s fixed premium is worth weighing against the cost of staying exposed. Comparing a personalized quote against your actual provider habits beats guessing.

— Zach

Get help comparing Medigap options and checking provider status

We work with residents on exactly this problem: matching you to a Medigap plan that fits your health needs and budget, then keeping it reviewed year after year. If excess charges are a concern because you see specialists often or travel for care, a Plan G quote is worth a look before your next enrollment window.

• We provide personalized Medigap Plan G and Plan N quotes based on your specific providers and health history.
• We offer Medicare planning support for new enrollees weighing Advantage versus Medigap.
• We conduct annual reviews so your coverage keeps pace with your care needs.
• We help with claims and appeals if a billing issue comes up after you’re enrolled.

If you are weighing Medigap against Medicare Advantage before deciding how to handle excess-charge risk, our Medicare Advantage vs. Medigap comparison walks through the trade-offs. When you are ready for numbers specific to your situation, start with our Medicare planning services and we will walk you through a quote.

This article is general information, not a substitute for advice from a qualified financial advisor. Consult a qualified financial professional about your own circumstances before acting on anything here.

FAQ

What states have banned Medicare excess charges?

Eight states restrict or ban Part B excess charges for care received within their borders: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont, according to Healthline’s state-by-state summary. These protections cover services delivered in that state, so care received elsewhere is not automatically protected.

Should I worry about Medicare excess charges?

For most beneficiaries, excess charges are not a frequent cost since the majority of providers accept assignment. If you see specialists who do not accept assignment, travel often for care, or want predictable costs, checking provider status or adding a Medigap Plan G is a reasonable precaution rather than a necessity for everyone.

What are examples of Medicare excess charges?

If a service has a $100 Medicare-approved amount, a non-participating provider can bill up to $115, adding $15 to your bill beyond your usual coinsurance, under Medicare’s limiting charge rule.

How common are Medicare Part B excess charges?

Non-participation and opt-out rates vary by specialty and location, with some specialties opting out more often than primary care, according to KFF’s tracking of physician participation. Checking a provider’s status before scheduling is the most reliable way to know your own risk.

Sources

• Does your provider accept Medicare as full payment? | Medicare
• How many physicians have opted out of the Medicare program? — KFF

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