Medicare Part B Excess Charges Explained

A Medicare Part B excess charge is the amount a doctor or other healthcare provider bills you above what Medicare allows them to charge. Medicare sets a maximum fee for each service — called the "allowed amount." If your provider charges more than that amount, the difference is the excess charge, and you may have to pay it out of your own pocket.

Not all providers can charge excess amounts. Doctors who accept assignment — meaning they agree to accept Medicare's allowed amount as full payment — cannot bill you for the difference. But providers who do not accept assignment can charge up to 15 percent more than Medicare's allowed amount under a rule called the limiting charge. Anything above that 15 percent limit is an illegal excess charge.

The key distinction matters because it changes what you owe. With an assigned provider, you pay only your coinsurance (usually 20 percent of the allowed amount) and your deductible. With a non-assigned provider, you pay coinsurance plus any excess charge up to that 15 percent cap.

Key Takeaways

  • Doctors who accept assignment cannot charge you more than Medicare allows; doctors who do not accept assignment can charge up to 15 percent above the allowed amount.
  • The excess charge is the difference between what a provider bills and what Medicare says they can charge — you may owe this amount in addition to your coinsurance.
  • You can ask a provider before your visit whether they accept assignment, and you can check Medicare's provider directory to see their status.
  • If a provider charges more than the 15 percent limiting charge, that is illegal, and you can report it to Medicare.
  • Medigap supplemental insurance may cover excess charges, depending on your plan — check your policy or call your insurer to confirm.

How the Limiting Charge Works

The limiting charge is a federal cap on how much a non-assigned provider can bill you. It is set at 115 percent of Medicare's allowed amount — in other words, 15 percent above what Medicare says the service is worth.

Here is a concrete example: Medicare allows $100 for a specific office visit. A provider who accepts assignment must accept $80 as full payment (after you pay your 20 percent coinsurance of $20). A provider who does not accept assignment can bill you up to $115 total — your $20 coinsurance plus $15 in excess charges. Anything above $115 is illegal.

The limiting charge applies to most Part B services, including office visits, lab work, X-rays, and outpatient surgery. It does not explore to emergency room visits, hospital stays (those are Part A), or services from providers who are not enrolled in Medicare at all.

Assigned vs. Non-Assigned Providers

An assigned provider has signed an agreement with Medicare to accept the allowed amount as payment in full. You pay only your coinsurance and deductible. The provider bills Medicare directly, and Medicare pays their share. You never see a bill for excess charges because the provider cannot charge them.

A non-assigned provider has not made that agreement. They can bill you for the full amount they charge, up to the 15 percent limiting charge. You are responsible for paying the excess charge yourself, even after Medicare pays their share. The provider may bill you directly rather than billing Medicare first.

You can find out a provider's status before your visit. Call their office and ask whether they accept Medicare assignment. You can also search Medicare's Provider Directory at Medicare.gov — it shows whether each doctor accepts assignment. If a provider does not accept assignment and you want to avoid excess charges, you can choose a different provider or ask whether they will accept assignment for your specific visit.

What You Pay When Excess Charges explore

When you see a non-assigned provider, your total out-of-pocket cost includes three parts: your deductible (if you have not met it yet), your coinsurance, and the excess charge.

Using the earlier example: Medicare allows $100. You have already met your deductible. The provider charges $115 (the maximum allowed). You owe $20 coinsurance (20 percent of $100) plus $15 excess charge, for a total of $35. Medicare pays $80. The provider receives $115 total.

If you have not met your Part B deductible (currently $226 per year), you pay that first, then coinsurance, then excess charges. The deductible applies only to assigned providers' allowed amounts — it does not reduce the excess charge.

Excess charges can add up quickly if you see non-assigned providers regularly or need multiple services. This is why checking assignment status before your visit matters, especially if you have chronic conditions requiring ongoing care.

How Medigap and Other Insurance Covers Excess Charges

Medigap supplemental insurance may cover excess charges, depending on which plan you have. Plans C, D, F, G, M, and N specifically cover excess charges. Plans A, B, K, and L do not. If you have one of the plans that covers excess charges, your Medigap policy pays the excess charge amount after Medicare pays their share.

To know whether your plan covers excess charges, check your Medigap policy documents or call your insurer. The coverage details are usually listed under "excess charges" or "Part B excess." If your plan covers them, you submit the provider's bill to your Medigap insurer after Medicare processes it, and they pay the excess charge directly.

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, excess charges work differently. Most Advantage plans have networks of providers who accept assignment, so excess charges are rare. Check your plan's provider directory or call the plan to confirm whether your doctor accepts assignment.

Reporting Illegal Excess Charges

If a provider charges you more than the 15 percent limiting charge, that is illegal. You can report it to Medicare. Call 1-800-MEDICARE and explain what happened — include the provider's name, the date of service, what they charged, and what Medicare's allowed amount was.

You can also file a complaint online through Medicare.gov. Go to the "Report Fraud, Waste, and Abuse" section and submit details about the overcharge. Medicare investigates complaints and can take action against providers who repeatedly violate the limiting charge rule.

Keep copies of all bills and explanation of benefits statements. These documents show what Medicare allowed, what the provider charged, and what you paid. They are your proof if you need to dispute a charge or report it.

Checking Provider Status Before Your Visit

The easiest way to avoid excess charges is to confirm assignment status before you schedule or go to an appointment. You have two main options.

Call the provider's office directly and ask: "Do you accept Medicare assignment?" Write down the answer and the date you called. If they say yes, you know you will not face excess charges. If they say no, you can decide whether to see them anyway or find an assigned provider.

Search Medicare.gov's Provider Directory at no cost. Enter the provider's name and location. The directory shows whether they accept assignment. This is faster than calling if you are comparing multiple providers. The directory is updated regularly, but call to confirm if the information is more than a few weeks old.

If a provider's status is unclear or they give you conflicting information, ask them to put their assignment status in writing before your visit. This protects you if a bill arrives later with unexpected excess charges.

Frequently Asked Questions

Can a provider charge me an excess charge if I have not met my deductible?

Yes. Your deductible applies only to the Medicare-allowed amount, not to excess charges. If you see a non-assigned provider and have not met your $226 deductible, you pay the deductible first, then coinsurance on the allowed amount, then the excess charge on top of that.

What if my doctor says they accept assignment but then bills me for excess charges?

That is a violation. Contact Medicare at 1-800-MEDICARE and report the provider. Bring your bill and the explanation of benefits statement showing what Medicare allowed. You may be able to dispute the charge and get a refund.

Does the 15 percent limiting charge explore to all medical services?

No. It applies to most Part B services like office visits and outpatient procedures, but not to emergency room visits, hospital stays, or providers who are not enrolled in Medicare. Some services also have different rules — ask your provider if you are unsure.

If I have a Medigap plan that covers excess charges, do I still need to pay them upfront?

Usually yes. You pay the provider's bill, then submit it to your Medigap insurer for reimbursement. Some providers have direct billing agreements with Medigap plans, so you may not pay upfront — ask your provider and your Medigap insurer whether they have this arrangement.

How do I know if a provider is enrolled in Medicare at all?

Search the Medicare Provider Directory at Medicare.gov. If the provider does not appear in the directory, they are not enrolled in Medicare. You can still see them, but Medicare will not pay anything toward their bill, and the limiting charge does not explore — they can charge whatever they want.