Part B Excess Charges: What They Are

Part B excess charges are amounts that doctors and other providers bill you above what Medicare says they can charge. Medicare sets a maximum price for each service — called the "allowed amount." If a doctor hasn't agreed to accept Medicare's price as full payment, they can bill you for the difference. That difference is the excess charge.

Not all doctors do this. Doctors who sign an agreement with Medicare to accept its allowed amount as full payment cannot bill you for excess charges — they are called "participating providers." Doctors who do not sign this agreement can charge more, and you pay the overage out of your own pocket. This charge does not count toward your Part B deductible or out-of-pocket maximum.

Excess charges can add up quickly, especially for frequent visits or expensive procedures. A single office visit, lab test, or imaging scan can result in a bill that is hundreds of dollars higher than what Medicare would have paid. Understanding which providers might charge excess amounts helps you plan your healthcare spending and avoid surprise bills.

Key Takeaways

  • Excess charges are amounts doctors bill above Medicare's allowed price, and they come directly out of your pocket.
  • Participating providers (those with a Medicare agreement) cannot charge excess amounts; non-participating providers can.
  • You can check whether a doctor participates in Medicare before your visit using the Medicare Provider Search tool on Medicare.gov.
  • Excess charges do not count toward your Part B deductible or annual out-of-pocket spending limit.
  • Some states have laws that limit or ban excess charges, so the rules depend partly on where you live.

Participating vs. Non-Participating Providers

A participating provider has signed a contract with Medicare agreeing to accept the Medicare allowed amount as full payment for all services. When you see a participating provider, you pay only your share of the allowed amount — typically your deductible (if you have not met it yet) and your coinsurance (usually 20 percent of the allowed amount). You will never receive a bill for excess charges from a participating provider.

A non-participating provider has not signed a Medicare contract. These doctors can charge up to 15 percent more than Medicare's allowed amount. For example, if Medicare's allowed amount for an office visit is $100, a non-participating provider can charge up to $115. You would owe the $20 coinsurance (20 percent of $100) plus the $15 excess charge, for a total of $35 out of pocket.

Some non-participating providers choose not to bill Medicare at all. These are called "non-Medicare providers" or "opt-out providers." They may ask you to sign a contract before treatment agreeing to pay their full fee, which could be much higher than Medicare's allowed amount. You should understand this agreement before you sign.

How to learn about Your Doctor Participates

Before your appointment, you can check whether a doctor accepts Medicare and whether they are a participating provider. The easiest way is to use the Medicare Provider Search tool on Medicare.gov. You enter the doctor's name and location, and the tool tells you whether they participate in Medicare, whether they accept new patients, and what their specialty is.

You can also call your doctor's office directly and ask: "Do you accept Medicare, and are you a participating provider?" A participating provider will say yes to both questions. If they say they do not participate, ask whether they are a non-participating provider (who can charge excess) or an opt-out provider (who may charge their own fee).

If you use a Medicare Advantage plan instead of Original Medicare, the rules are different. Your plan has its own network of providers, and you should check your plan's provider directory or call your plan to see which doctors are in network. Out-of-network providers in Medicare Advantage plans may charge you more.

State Laws That Limit Excess Charges

Some states have passed laws that limit or ban excess charges entirely. These state laws override the federal 15 percent limit, meaning doctors in those states cannot charge excess amounts at all, or can charge only a smaller percentage. The states with the strictest rules include Connecticut, Florida, Illinois, Maryland, New York, Ohio, Pennsylvania, and Texas, though the specific rules vary by state.

If you live in one of these states, you may have more protection against excess charges than someone in another state. However, the rules are complex and change over time. If you receive a bill for an excess charge and you believe it violates your state's law, you can contact your state's insurance commissioner's office or your state's attorney general for guidance.

Even if your state does not have a specific excess charge law, you can file a complaint with Medicare if you believe a provider has charged you unfairly. Medicare investigates complaints and can take action against providers who violate the rules.

What to Do If You Receive an Excess Charge Bill

If you receive a bill that includes an excess charge, first check whether the provider is truly non-participating. Look up the provider in the Medicare Provider Search tool to confirm. If the tool shows they are a participating provider, the bill is wrong, and you should contact the provider's billing office and ask them to correct it.

If the provider is non-participating and the excess charge is within the 15 percent federal limit (or your state's limit), the charge is technically allowed. However, you can still ask the provider to waive the excess charge, especially if you were not told about it beforehand. Some providers will negotiate or remove the charge if you ask.

Keep copies of all bills and explanations of benefits (EOBs) from Medicare. Your EOB shows what Medicare paid and what you owe. If you see charges on your bill that do not match your EOB, contact Medicare at 1-800-MEDICARE to report it. You can also file a complaint with your state's insurance commissioner if you believe the charges are unfair.

How Excess Charges Affect Your Medicare Costs

Excess charges are separate from your Part B deductible and coinsurance. Your Part B deductible (currently $240 per year, though this amount changes yearly) applies only to the Medicare allowed amount, not to excess charges. Similarly, your annual out-of-pocket maximum does not include excess charges. This means excess charges can push your total healthcare spending much higher than you planned.

If you see multiple non-participating providers, excess charges can become a significant expense over time. For this reason, many people choose to see only participating providers when possible. If you need to see a non-participating provider, ask about their fees upfront and factor excess charges into your healthcare budget.

If you have a Medigap (supplemental insurance) plan, some Medigap plans cover excess charges. Plans F and G, for example, cover the full excess charge amount. If you have a different Medigap plan, check your plan documents or call your insurance company to see whether excess charges are covered. This is one reason why Medigap coverage can be valuable for people who see non-participating providers.

Frequently Asked Questions

Can a participating provider ever charge me an excess charge?

No. Participating providers have signed an agreement with Medicare to accept the allowed amount as full payment. They cannot bill you for any amount above that, even if their usual fee is higher. If a participating provider sends you an excess charge bill, contact Medicare or your state's insurance commissioner.

What is the maximum excess charge a non-participating provider can bill?

Federal law allows non-participating providers to charge up to 15 percent above Medicare's allowed amount. However, some states have lower limits or ban excess charges entirely. Check your state's rules or ask the provider what they charge before your visit.

Does my Medigap plan cover excess charges?

Some Medigap plans do, and some do not. Medigap Plan F and Plan G cover excess charges in full. Other plans may cover part or none of the excess charge. Check your plan documents or call your insurance company to find out what your plan covers.

If I did not know about excess charges before my visit, can I dispute the bill?

You can ask the provider to waive the charge, especially if you were not informed beforehand. You can also file a complaint with Medicare or your state's insurance commissioner. While you may not always win, providers sometimes remove charges when questioned, particularly if the patient was not given clear notice.

How do I know if a provider is participating before I make an appointment?

Use the Medicare Provider Search tool on Medicare.gov, or call the provider's office and ask directly: "Are you a participating Medicare provider?" A participating provider will confirm that they accept Medicare and will not charge excess amounts.