States that prohibit Medicare excess charges generally include Massachusetts, Minnesota, Ohio and Pennsylvania. These four states have broad laws that prevent the ordinary Medicare Part B excess charges most people mean when they ask this question.
However, the rules are not identical. Minnesota has specific exceptions, Massachusetts law focuses on physicians, and state protections usually do not follow a resident who receives care in another state.
Many websites list eight states and add Connecticut, New York, Rhode Island and Vermont. That shorthand is misleading. Those four states have special Medicare billing rules, but their current laws do not create a complete prohibition for every Medicare beneficiary and every covered service.
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States That Prohibit Medicare Excess Charges: The Short Answer
The four states with the clearest broad protections are:
- Massachusetts
- Minnesota
- Ohio
- Pennsylvania
Even in these states, it is important to understand the exact scope of the law. No state rule turns a service Medicare does not cover into a covered service. State balance-billing protections also do not make private-contract care from a provider who has opted out of Medicare payable by Medicare or a Medicare Supplement policy.
The location where you receive care matters. A Pennsylvania resident who visits a non-participating provider in a state that allows excess charges may still be billed a legally permitted excess charge. Plan G covers qualifying excess charges. Plan N does not.
What Is a Medicare Part B Excess Charge?
A Medicare Part B excess charge is an additional amount that certain non-participating providers may bill above Medicare’s approved amount for a covered Part B service.
An excess charge may apply only when several conditions are met:
- The provider is enrolled in Medicare.
- The provider is non-participating.
- The provider declines Medicare assignment for the 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 participating Medicare provider accepts assignment for covered services and cannot add an excess charge.
Medicare commonly describes the federal limiting charge as no more than 15% above the Medicare-approved amount for a non-participating provider. The complete calculation uses 115% of the reduced non-participating approved amount, which is generally 95% of the full participating Medicare Physician Fee Schedule amount.
How the Rules Work in the Four Broad-Protection States
Massachusetts
Massachusetts makes Medicare assignment a condition of physician licensing. A licensed physician who agrees to treat a Medicare beneficiary must agree not to charge or collect more than the reasonable charge determined by the U.S. Department of Health and Human Services.
This is a broad protection against physician excess charges. It does not mean every possible healthcare bill is limited by the same statute, and it does not apply to private-contract charges from providers who have opted out of Medicare.
Minnesota
Minnesota law generally prevents a healthcare provider from charging a Minnesota resident more than the Medicare-approved amount for a Medicare-covered service.
The statute contains specific exceptions for ambulance services and medical supplies and equipment. A supplier that does not accept assignment must notify a Minnesota Medicare beneficiary before the purchase or lease that it charges more than the Medicare-approved amount.
Minnesota’s law is therefore broad, but it should not be described as an exception-free ban covering every Part B item and service.
Ohio
Ohio law states that a healthcare practitioner, or a person employing a healthcare practitioner, may not balance bill for supplies or services provided to a Medicare beneficiary.
Ohio has one of the clearest broad prohibitions in the country. As with the other states, the rule does not transform a private agreement with an opted-out provider into a Medicare-covered claim.
Pennsylvania
Pennsylvania’s Health Care Practitioners Medicare Fee Control Act makes it unlawful for licensed healthcare practitioners and the entities that employ them to balance bill Medicare beneficiaries.
For Medicare-covered care received from practitioners in Pennsylvania, this generally prevents a provider from adding a Part B excess charge above Medicare’s approved amount.
Pennsylvania residents should still consider where they receive care. The Pennsylvania law does not necessarily protect someone who receives treatment from a provider in another state. This out-of-state exception is particularly relevant for people who travel frequently, spend part of the year elsewhere or receive specialized treatment across state lines.
Why Do Some Lists Name Eight States?
Articles about states that prohibit Medicare excess charges often repeat an eight-state list that includes:
- Connecticut
- Massachusetts
- Minnesota
- New York
- Ohio
- Pennsylvania
- Rhode Island
- Vermont
The problem is that this list treats different state laws as though they all impose the same complete ban. They do not.
Massachusetts, Minnesota, Ohio and Pennsylvania have broad statutory protections. Connecticut, New York, Rhode Island and Vermont require separate explanations because excess charges remain possible in at least some ordinary situations.
States Often Misclassified as Complete-Prohibition States
Connecticut
Connecticut does not prohibit Part B excess charges for every Medicare beneficiary.
Connecticut’s official Medicare counseling program states that traditional Medicare beneficiaries may be charged Part B excess charges unless they are enrolled in the Qualified Medicare Beneficiary, or QMB, program. QMB beneficiaries have separate federal protections against Medicare cost-sharing bills.
Connecticut should therefore not be presented as a blanket no-excess-charge state.
New York
New York restricts excess charges but does not eliminate them.
For most services, New York generally limits a non-participating physician to 5% above Medicare’s approved payment amount. Certain home and office evaluation-and-management visits may remain subject to the federal limiting charge of up to 15% above the applicable approved amount.
New York provides stronger protection than the federal rule for many services, but it is a reduced limit rather than a complete prohibition.
Rhode Island
Rhode Island requires physicians to disclose to Medicare patients whether they accept Medicare assignment.
If a physician fails to make the required disclosure, the physician may not charge more than the Medicare assignment amount. The law does not say that every physician who properly makes the disclosure must accept assignment.
Rhode Island is therefore better described as a disclosure state with an assignment penalty for noncompliance, not a state that completely prohibits excess charges.
Vermont
Vermont generally prohibits physicians who agree to treat Medicare beneficiaries from balance billing, but the statute contains meaningful exceptions.
A physician may balance bill in certain circumstances involving the beneficiary’s taxable Social Security or railroad retirement benefits, a refusal to sign the state-authorized statement, or an office or home visit.
Because excess charges remain possible under these statutory exceptions, Vermont should not be described as having an absolute ban.
Non-Participating Providers and Opt-Out Providers Are Different
A non-participating provider is still enrolled in Medicare. The provider may accept assignment for one claim and decline it for another.
When a non-participating provider accepts assignment for your claim, there is no excess charge. When the provider declines assignment, a legally permitted excess charge may apply up to the applicable federal or state limit.
An opted-out provider operates differently. The provider generally:
- Does not submit ordinary claims to Medicare
- Uses a private contract with the patient
- Sets a private fee
- Requires the patient to agree to pay personally
Except for certain emergency or urgently needed services, Medicare generally does not pay for care furnished under an opt-out private contract. The private fee is not a Medicare Part B excess charge, and Plan G’s excess-charge benefit does not cover an unlimited private-contract bill.
How State Rules Affect Plan G and Plan N
Standard Medicare Supplement Plan G covers qualifying Medicare Part B excess charges. Plan N does not.
For someone who receives nearly all care in Massachusetts, Minnesota, Ohio or Pennsylvania, excess-charge exposure may be limited by state law. That can make Plan N more attractive when its premium is meaningfully lower than Plan G.
The comparison still involves more than excess charges:
- Plan N may require up to a $20 copay for certain office visits.
- Plan N may require up to a $50 emergency-room copay when the visit does not result in inpatient admission.
- Plan G does not use those Plan N office and emergency-room copays.
- Plan G covers qualifying excess charges throughout the United States.
- Plan N may have a lower monthly premium.
Frequent travelers may place more value on Plan G’s excess-charge coverage. Someone who receives nearly all care in Pennsylvania and verifies Medicare assignment when traveling may decide the premium savings available with Plan N are more valuable.
How to Avoid Excess Charges When You Travel
State protections generally depend on the law where the provider practices and the care is received. Do not assume that your home state’s law follows you across state lines.
Before receiving non-emergency care, ask the provider’s billing office:
- Are you a participating Medicare provider?
- Do you accept Medicare assignment?
- Will you accept assignment for my specific service?
- Are you non-participating, or 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 take Medicare” is not specific enough. A non-participating provider may still take Medicare while declining assignment for a particular claim.
You can also review the provider in Medicare’s Care Compare directory and compare any bill with your Medicare Summary Notice before paying an unfamiliar additional amount.
Frequently Asked Questions
How many states prohibit Medicare excess charges?
The phrase “states that prohibit Medicare excess charges” applies most cleanly to Massachusetts, Minnesota, Ohio and Pennsylvania. Each statute has its own scope, and Minnesota has explicit exceptions for ambulance services and medical supplies and equipment.
Does Connecticut prohibit Medicare excess charges?
No, not for every Medicare beneficiary. Connecticut’s official Medicare counseling program says excess charges may apply to traditional Medicare beneficiaries unless they have QMB protection.
Are Medicare excess charges prohibited in New York?
Not completely. New York generally limits non-participating physicians to 5% above Medicare’s approved amount for most services, while certain home and office visits may be subject to the federal 15% limit.
Can Pennsylvania residents be charged excess charges while traveling?
Yes. Pennsylvania’s protection does not necessarily apply when a Pennsylvania resident receives care from a provider in another state that permits excess charges.
Does Plan N cover Medicare excess charges?
No. Standard Medicare Supplement Plan N does not cover Part B excess charges. Plan N’s office and emergency-room copays are separate expenses.
Does Plan G cover Medicare excess charges?
Yes. Standard Medicare Supplement Plan G covers 100% of qualifying Medicare Part B excess charges when they are legally permitted.
Can an opted-out doctor charge more than Medicare allows?
An opted-out provider may use a private contract and set a private fee. That bill is not a Medicare excess charge because Medicare is generally not processing the service under its normal payment rules.
How do I know whether my doctor accepts Medicare assignment?
Ask the billing office directly whether the provider accepts Medicare assignment for your specific service. You can also check Medicare’s Care Compare directory and review your Medicare Summary Notice after the claim is processed.
Related Medicare Topics
- What Are Medicare Part B Excess Charges?
- Do Medicare Excess Charges Actually Happen?
- Can Doctors Charge Medicare Excess Charges in Pennsylvania?
- Plan G vs Plan N
- Why I Recommend Medicare Supplement Plan N So Often
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