What Are Medicare Part B Excess Charges?

Medicare Part B excess charges are amounts that certain non-participating Medicare providers may legally bill above Medicare’s approved amount for a covered service.

They do not apply every time you visit a doctor who accepts Medicare. An excess charge can generally occur only when a provider is enrolled in Medicare, is non-participating, does not accept Medicare assignment for your claim, and is permitted by state and federal law to charge more than Medicare’s approved amount.

Medicare Supplement Plan G covers qualifying Part B excess charges. Plan N does not. Understanding exactly how these charges work can help you compare Medicare Supplement plans without confusing excess charges with deductibles, coinsurance, copays, or private-contract fees.

How Do Medicare Part B Excess Charges Work?

Medicare establishes an approved payment amount for covered services. When a provider accepts Medicare assignment, the provider agrees to accept that approved amount as payment in full.

After you satisfy the annual Medicare Part B deductible, Medicare generally pays 80% of the approved amount for most covered Part B services. You or your Medicare Supplement policy are responsible for the remaining 20%.

A provider who accepts assignment cannot add a Medicare Part B excess charge.

An excess charge may become possible when:

The provider is enrolled in Medicare
The provider is non-participating
The provider does not accept assignment for your specific claim
The service is subject to Medicare’s limiting-charge rules
State law permits the additional charge
The provider actually bills more than Medicare’s approved amount

A provider’s non-participating status alone does not create an excess charge. The provider must also decline assignment for the claim and bill above the applicable Medicare-approved amount.

What Does Accepting Medicare Assignment Mean?

Accepting assignment means the provider agrees to accept Medicare’s approved amount as payment in full for the covered service.

The provider can still collect:

Your Medicare Part B deductible
Your normal Part B coinsurance
Payment for services Medicare does not cover
Other amounts Medicare says you are responsible for

However, the provider cannot impose a Part B excess charge on an assigned Medicare claim.

There are three important provider classifications:

Provider Status	How Medicare Billing Generally Works	Can an Excess Charge Apply?
Participating provider	Agrees to accept assignment for all Medicare-covered services	No
Non-participating provider	Remains enrolled in Medicare and may accept assignment claim by claim	Possibly, when assignment is declined and the charge is legally permitted
Opt-out provider	Uses a private contract and generally does not submit ordinary claims to Medicare	Private-contract fees are not Medicare excess charges

The most important question is not merely whether a provider “takes Medicare.” Ask whether the provider accepts Medicare assignment for your service.

Participating and Non-Participating Providers Are Different

A participating Medicare provider has signed an agreement to accept Medicare assignment for all covered services furnished to Medicare beneficiaries.

A non-participating provider is still enrolled in Medicare but has not made that same blanket commitment. The provider may:

Accept assignment for one claim
Decline assignment for another claim
Require payment at the time of service
Submit the Medicare claim as an unassigned claim
Charge up to the applicable limiting charge when legally permitted

Therefore, a non-participating provider does not automatically charge every Medicare patient more.

When a non-participating provider accepts assignment for your claim, there is no excess charge.

How Is the Medicare Limiting Charge Calculated?

Medicare commonly describes the limiting charge as no more than 15% above the Medicare-approved amount for a non-participating provider.

The complete calculation is slightly more complicated because the approved payment amount for a non-participating physician is generally 95% of the full Medicare Physician Fee Schedule amount.

The limiting charge is then calculated as 115% of that reduced non-participating amount.

Suppose the full participating Medicare Physician Fee Schedule amount for a service is $100:

Calculation	Amount
Full participating fee-schedule amount	$100.00
Non-participating approved amount at 95%	$95.00
Maximum limiting charge at 115% of $95	$109.25
Maximum excess above the $95 approved amount	$14.25

The provider’s maximum total charge in this example would be $109.25—not $115.

The $14.25 difference between the $95 non-participating approved amount and the $109.25 limiting charge is the Medicare Part B excess charge.

This means the maximum limiting charge ordinarily equals 109.25% of the full participating fee-schedule amount.

Actual Medicare-approved amounts vary by service, geographic area, and other payment factors.

Does the Limiting Charge Apply to Every Part B Service?

No. Medicare’s limiting charge applies to certain services furnished by non-participating providers who do not accept assignment.

It does not apply uniformly to every item, service, provider, or supplier covered by Medicare Part B. Different billing rules may apply to certain medical equipment, supplies, clinical laboratory services, and other categories of care.

Before assuming that an additional bill is a valid excess charge, confirm:

Whether Medicare covered the service
Whether the provider was enrolled in Medicare
Whether the provider accepted assignment
Whether the service was subject to the limiting charge
Whether state law allowed the additional amount
What your Medicare Summary Notice says you owe

An unfamiliar medical bill is not automatically a Medicare excess charge.

What Is Not a Medicare Part B Excess Charge?

Several ordinary Medicare expenses are sometimes mistaken for excess charges.

The following are not Medicare Part B excess charges:

The annual Medicare Part B deductible
Your normal 20% Part B coinsurance
A Plan N office-visit copay
A Plan N emergency-room copay
A charge for a service Medicare does not cover
A private-contract fee from an opt-out provider
The cost of routine dental, vision, or hearing services that Medicare does not cover
A Medicare Advantage plan’s copay or out-of-network cost
A foreign medical bill for care that Original Medicare does not cover

An excess charge has a specific meaning: it is the legally permitted difference between the provider’s actual charge and Medicare’s approved amount for a covered Part B service.

Opt-Out Providers Are Not Charging Medicare Excess Charges

A provider who has opted out of Medicare is different from a non-participating provider.

An opt-out provider generally:

Does not submit ordinary claims to Medicare
Uses a private contract with the patient
Requires the patient to agree to pay personally
Is not limited to Medicare’s approved amount under the private contract

Except for certain emergency or urgently needed services, Medicare generally does not pay for care furnished under an opt-out private contract.

The amount charged under that contract is not a Medicare Part B excess charge. It is a private fee for a service Medicare is not processing under its ordinary payment rules.

Plan G’s excess-charge benefit does not cover unlimited private-contract fees from an opt-out provider. Medicare Supplement plans generally supplement Medicare-covered expenses; they do not create Medicare coverage for private-contract services.

Which Medicare Supplement Plans Cover Excess Charges?

Among the standardized Medicare Supplement plans used in most states, Plan F and Plan G cover 100% of qualifying Medicare Part B excess charges.

Medicare Supplement Plan	Part B Excess-Charge Coverage
Plan F	Covered
Plan G	Covered
Plan N	Not covered
Plans A, B, C, D, K, L and M	Not covered

Plan F is generally unavailable to people who became eligible for Medicare on or after January 1, 2020. People eligible for Medicare before that date may still be able to purchase Plan F when it is offered and they meet the applicable enrollment or underwriting requirements.

High-deductible Plan F and high-deductible Plan G also include excess-charge coverage, but the policy does not begin paying benefits until the applicable high deductible has been satisfied.

Medigap policies are standardized differently in Massachusetts, Minnesota, and Wisconsin, so plan names and excess-charge options work differently in those states.

Does Medicare Supplement Plan G Cover Excess Charges?

Yes. Standard Medicare Supplement Plan G covers qualifying Medicare Part B excess charges when they are legally permitted.

Plan G also covers the normal Part B coinsurance after you satisfy the annual Part B deductible.

If a non-participating provider declines assignment and bills a valid excess charge, Plan G should cover that amount according to the policy’s terms.

This does not mean Plan G covers:

Private-contract fees from opt-out providers
Services Medicare does not cover
Amounts above Medicare’s legal limiting charge
Charges prohibited by state law
The annual Medicare Part B deductible

How the claim is paid can vary. Medicare and the Medicare Supplement company may process the claim automatically, or the policyholder may need to provide documentation and request reimbursement.

Does Medicare Supplement Plan N Cover Excess Charges?

No. Medicare Supplement Plan N does not cover Medicare Part B excess charges.

If a qualifying excess charge is legally billed, the Plan N policyholder is responsible for that amount.

Plan N still covers the same major standardized hospital benefits as Plan G. It also covers the Part B coinsurance except for up to $20 for some office visits and up to $50 for an emergency-room visit that does not result in inpatient admission.

Those Plan N copays are separate from Medicare excess charges.

Whether the lack of excess-charge coverage should affect your decision depends on where you receive care, whether your providers accept assignment, and the premium difference between Plan G and Plan N.

Can State Law Prohibit Medicare Excess Charges?

Yes. A state can provide Medicare beneficiaries with stronger balance-billing protections.

When state law prohibits Medicare excess charges, a practitioner cannot impose the charge merely because the practitioner is non-participating or declined assignment.

Pennsylvania’s Health Care Practitioners Medicare Fee Control Act prohibits healthcare practitioners from balance billing Medicare beneficiaries above Medicare’s approved amount for covered services received in Pennsylvania.

The location where the care is furnished matters. Pennsylvania’s protection does not necessarily apply when a Pennsylvania resident receives medical care in another state.

Private-contract fees from providers who have opted out of Medicare remain a separate issue.

How Can You Determine Whether a Provider Accepts Assignment?

Before scheduling non-emergency care, ask the provider’s billing office:

Do you accept Medicare?
Are you a participating Medicare provider?
Do you accept Medicare assignment?
Will you accept assignment for my specific service?
Are you a non-participating Medicare provider?
Have you opted out of Medicare?
Will I be asked to sign a private contract?
Could I be billed more than Medicare’s approved amount?

The phrase “we accept Medicare” can be unclear. It may mean the provider is enrolled in Medicare without confirming that the provider accepts assignment.

Asking specifically about Medicare assignment gives you a more useful answer.

What Should You Do if You Receive an Excess-Charge Bill?

Start by comparing the provider’s bill with your Medicare Summary Notice.

Review:

The service Medicare processed
Medicare’s approved amount
Whether Medicare paid the provider or paid you
Whether the provider accepted assignment
The amount Medicare says you may owe
Whether your Medicare Supplement policy processed the claim

If you have Plan G or another policy covering excess charges, contact the Medicare Supplement company if the benefit was not paid.

If you have Plan N, confirm that the charge was legally permitted and did not exceed Medicare’s limiting charge before paying it.

You can contact Medicare at 1-800-MEDICARE if the provider’s bill does not match your Medicare Summary Notice or you need help understanding the claim.

The Bottom Line on Medicare Part B Excess Charges

Medicare Part B excess charges can occur when a non-participating provider declines Medicare assignment and legally bills more than Medicare’s approved amount for a covered service.

Participating providers cannot impose excess charges. Non-participating providers do not automatically impose them because they can accept assignment on a claim-by-claim basis. Opt-out providers and their private contracts operate under different rules.

The limiting charge is generally 115% of the reduced non-participating payment amount. That ordinarily produces a maximum total charge equal to 109.25% of the full participating Medicare Physician Fee Schedule amount.

Standard Plan F and Plan G cover qualifying Part B excess charges. Plan N does not.

The separate question of how frequently these charges actually occur is covered in our real-world Medicare excess-charges page linked below.

Frequently Asked Questions

What is the maximum Medicare Part B excess charge?

The limiting charge is generally 115% of the non-participating approved amount. Because that approved amount is ordinarily 95% of the full participating fee-schedule amount, the maximum total charge usually equals 109.25% of the full participating amount.

Can a participating Medicare provider charge an excess charge?

No. Participating providers agree to accept Medicare assignment for covered services and cannot bill more than Medicare’s approved amount.

Does every non-participating provider charge excess charges?

No. A non-participating provider may accept assignment on a claim-by-claim basis. No excess charge applies when the provider accepts assignment.

Does Plan G cover Medicare Part B excess charges?

Yes. Standard Medicare Supplement Plan G covers 100% of qualifying Part B excess charges when they legally apply.

Does Plan N cover Medicare Part B excess charges?

No. Plan N does not cover Part B excess charges. Its office and emergency-room copays are separate expenses and are not excess charges.

Is an opt-out doctor’s bill considered an excess charge?

No. An opt-out provider generally uses a private contract and does not submit an ordinary claim to Medicare. Private-contract fees are not Medicare Part B excess charges.

Can Medicare excess charges apply to services Medicare does not cover?

No. A charge for a noncovered service is not a Medicare excess charge. Excess charges involve covered Part B services processed under Medicare’s payment rules.

Can doctors charge Medicare excess charges in Pennsylvania?

Pennsylvania prohibits healthcare practitioners from balance billing Medicare beneficiaries above Medicare’s approved amount for covered services received in Pennsylvania. Out-of-state care and private contracts with opt-out providers are separate situations.

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