You can owe up to 15% more when a doctor does not accept Medicare assignment — that extra fee is called a Medicare Part B excess charge. If a provider doesn’t accept Medicare’s approved amount, you may have to pay the difference out of pocket, unless your Medigap plan covers it.
Knowing this helps you avoid surprise bills and plan for care costs. This article will explain how excess charges are calculated, which providers can bill them, and which states limit or ban them.
You’ll learn how Medigap can protect you, how to check whether a doctor accepts Medicare assignment, and practical steps to lower your chances of facing extra fees. If you want one-on-one help, The Modern Medicare Agency can guide you through your options.
Our licensed agents speak with you directly, match Medicare packages to your needs, and help avoid plans that add unnecessary costs — all without charging extra fees.
Understanding Medicare Excess Charges
Medicare excess charges are extra amounts some doctors can bill you beyond what Medicare pays. You need to know how they form, which services often carry them, and how to avoid surprise bills.
Definition of Medicare Excess Charges
A Medicare excess charge is the extra fee a provider can bill you when they do not accept Medicare assignment. Medicare sets an approved amount for each service.
If a doctor opts out of assignment, they can charge up to 15% more than that approved amount. You still pay your Part B deductible and coinsurance in addition to any excess charge.
Not all providers charge the full 15%; some add 5% or 10% instead. Medigap plans vary: some cover excess charges and some do not.
How Excess Charges Originate
Excess charges arise when a provider refuses Medicare assignment. Accepting assignment means the provider agrees to accept Medicare’s approved amount as full payment.
When providers decline, they can set their own fee above Medicare’s rate. Medicare notifies you of the approved amount on your Explanation of Benefits.
Providers must tell you if they won’t accept assignment for a visit. You can avoid excess charges by choosing providers who accept assignment or by selecting a Medigap plan that covers excess charges.
Services Commonly Subject to Excess Charges
Excess charges most often appear for office visits, outpatient procedures, and specialist consultations. Lab tests and imaging may also carry extra fees if the provider doesn’t accept assignment.
Emergency services billed by an out-of-network doctor can generate excess charges too. Before scheduling non-emergency services, ask the provider if they accept Medicare assignment and request a written estimate if you expect higher costs.
Why choose The Modern Medicare Agency? Our licensed agents are real people you can speak with one-on-one.
They match Medicare packages to your needs and help you find providers who accept assignment, all without extra fees that break the bank.
How Medicare Excess Charges Work
Medicare excess charges happen when a provider bills more than what Medicare approves. You need to know when providers can add a fee, how that fee is figured, and the legal cap on extra charges.
Role of Medicare Assignment
Medicare assignment is an agreement where a doctor accepts the Medicare-approved amount as full payment. If a provider accepts assignment, you pay only your Part B coinsurance or deductible and no extra charge from that provider.
If a provider does not accept assignment, they can bill you beyond Medicare’s approved amount. You still get reimbursed by Medicare for its share, but you must pay the difference between the provider’s charge and the Medicare-approved amount, plus your usual out-of-pocket share.
Your best protection is to confirm assignment before care. Ask the office whether they accept Medicare assignment and get it in writing when possible.
The Modern Medicare Agency can help you check provider assignment status and explain how it affects your costs.
Calculation of Excess Charges
Excess charges equal the provider’s billed amount minus the Medicare-approved amount. For example, if Medicare approves $100 for a service and the provider bills $110, the excess charge is $10.
Medicare pays its portion of the approved amount directly to you or the provider depending on assignment. You then owe the excess plus any coinsurance or deductible you already owe.
Keep receipts and Medicare statements to verify calculations. If you have a Medigap plan, certain plans cover excess charges.
Check your specific Medigap benefits or talk to an agent who can compare plans and tell you whether your plan will cover the difference.
Limits on Excess Charges
Federal rules cap Medicare Part B excess charges at 15% above the Medicare-approved amount. That means a provider cannot bill you more than 115% of the approved amount for most services.
Not all providers can charge excess fees. Providers who accept assignment cannot impose excess charges.
Also, Medicare Advantage plans generally use different cost rules and typically do not allow traditional excess charges. If a provider violates the cap or misrepresents assignment, report it to Medicare and consider contacting a licensed agent at The Modern Medicare Agency.
Our agents are real people you can speak to one-on-one, and they help you find Medicare packages that match your needs without charging extra fees that break the bank.
Providers and Acceptance of Medicare Assignment
Knowing whether a provider accepts Medicare assignment affects how much you pay and whether you risk extra charges. This section explains the difference between provider types and how your choice can change out-of-pocket costs.
Participating vs. Non-participating Providers
Participating providers sign an agreement with Medicare to accept the Medicare-approved amount as full payment. When a participating doctor bills Medicare directly, you only pay the Part B deductible and the coinsurance or copay that Medicare allows.
You will not face extra or “balance” bills beyond those amounts. Non-participating providers do not always accept the Medicare-approved amount.
They may accept assignment for certain services but can also bill above Medicare’s approved rate. That extra charge is called an excess charge and can be up to 15% over Medicare’s approved amount.
If you see a non-participating provider, ask in advance whether they accept assignment for the service you need so you know if an excess charge might apply.
How Provider Choice Affects Excess Charges
If you use a participating provider, you avoid excess charges entirely. That reduces your financial risk for covered services under Original Medicare.
Participating providers bill Medicare directly and follow Medicare’s payment rules. If you choose a non-participating provider, plan for possible extra costs.
Non-participating providers can charge up to 15% more than Medicare’s approved amount for Medicare-covered services. These excess charges are separate from your deductible and coinsurance.
Check provider status before an appointment. If you need help comparing plans or finding providers who accept assignment, contact The Modern Medicare Agency.
Our licensed agents speak with you one-on-one, match Medicare packages to your needs, and don’t add extra fees.
States With Restrictions on Excess Charges
Some states stop doctors from charging more than Medicare allows, while others add rules that protect you in specific ways. Know which states ban excess charges and what extra protections you might have so you aren’t surprised by out‑of‑pocket costs.
States That Prohibit Excess Charges
Eight states currently prohibit Medicare Part B excess charges. These states are Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.
If you live in one of these states, non‑participating providers cannot bill you the extra 15% above the Medicare‑approved amount. If you move or travel, check billing practices in the state where you get care.
Even inside these states, confirm with your provider that they will not issue an excess charge and always ask whether they accept Medicare assignment before services.
State-specific Protections for Beneficiaries
Some states add rules beyond outright bans. Protections can include limits on surprise billing, tighter enforcement of billing laws, and clearer appeal rights if you get billed incorrectly.
These measures make it easier for you to contest improper charges and reduce unexpected costs. If you want help understanding how state rules affect your plan choices, contact The Modern Medicare Agency.
Our licensed agents are real people you can speak with one‑on‑one. They’ll review your needs, explain state rules that matter to you, and find Medicare plans without extra fees that break the bank.
Impact on Beneficiaries
You may face extra costs and new billing steps if a provider charges more than the Medicare-approved amount. Know what you might pay and what tasks fall to you when that happens.
Out-of-pocket Costs
If a provider does not accept Medicare assignment, they can charge up to 15% more than the Medicare-approved amount. That extra fee, called the excess charge, does not count toward your Medicare Part B deductible.
You still pay the standard Part B coinsurance or copay, then add the excess charge on top. Examples:
- If Medicare pays $100, a non-assigned provider can bill you up to $115.
- You would owe your coinsurance plus the excess charge, increasing your bill significantly for some services.
Medigap Plans F and G can cover excess charges in many cases. Plan F is not available to new Medicare enrollees since 2020, so check Plan G or other supplements.
The Modern Medicare Agency can help you compare plans and find one that limits your out-of-pocket exposure.
Billing Processes and Patient Responsibilities
When a provider does not accept assignment, they must tell you in writing before giving non-emergency services. You should receive an Advance Beneficiary Notice or a clear statement that the provider will charge excess amounts.
Review any written notice carefully before you agree to the service. You are responsible for:
- Asking whether the provider accepts Medicare assignment.
- Requesting a cost estimate in writing for non-emergency care.
- Keeping copies of notices and bills to dispute errors.
If a bill seems wrong, contact the provider first. If that does not resolve it, call Medicare or get help from The Modern Medicare Agency.
Our licensed agents will talk with you 1 on 1, review statements, and help you understand whether charges are valid and which plan options reduce your risk.
Medigap and Coverage for Excess Charges
Medigap can fill gaps in Original Medicare by paying certain out-of-pocket costs that Medicare doesn’t cover. Some Medigap plans specifically handle Part B excess charges, and choosing the right one affects how much you pay when a provider charges above the Medicare-approved amount.
Medigap Plans That Cover Excess Charges
Only a few Medigap plans cover Part B excess charges. Plan G covers excess charges, and Plan F also does but is only available if you were eligible for Medicare before January 1, 2020.
If you have either plan, Medicare pays its share first, and then your Medigap policy can pay the amount the provider adds above the Medicare-approved fee (up to the legal 15% limit where allowed). Check if your state allows excess charges.
In states that ban them, this issue won’t apply. Also confirm whether your current or prospective doctors accept Medicare assignment; if they do, excess charges won’t occur.
Ask about excess-charge coverage when you shop for plans so you avoid surprise bills.
Selecting a Medigap Plan for Protection
Decide based on your health habits and provider network. If you visit doctors who don’t accept Medicare assignment, a plan that covers excess charges will protect you from those extra costs.
Compare premiums: plans that cover excess charges often cost more, so weigh the premium against how often you expect to face excess charges. Talk with a licensed agent to match a plan to your needs.
The Modern Medicare Agency offers real, licensed agents who speak with you one-on-one, review your provider list, and identify Medigap packages that fit your budget without hidden fees. That personal help can simplify choices and reduce the chance of unexpected bills.
Steps to Avoid Paying Medicare Excess Charges
You can prevent extra Part B fees by checking whether a provider accepts Medicare assignment and by getting a clear assignment agreement before care. Both steps take minutes but can save you up to 15% per visit.
Verifying Provider Participation
Call the provider’s office and ask directly if they accept Medicare assignment for the specific service you need. Confirm whether they bill Medicare directly and accept the Medicare-approved amount as full payment.
Check the provider’s participation for each visit. Some doctors accept assignment for some services but not others.
Ask for written confirmation or an email so you have proof if a charge appears later. If you live in Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, state rules may already limit excess charges.
Still verify with the provider to avoid surprises. The Modern Medicare Agency can help you check providers.
Our licensed agents will call on your behalf and confirm assignment status so you don’t get unexpected bills.
Using Assignment in Advance
Ask the provider to sign an assignment agreement before treatment. Assignment means the provider agrees to accept the Medicare-approved amount as full payment for the service.
Get the assignment in writing and keep a copy. If a provider later tries to bill you more, your documentation helps resolve disputes with Medicare or the provider’s billing office.
If a provider refuses assignment, consider switching to a different doctor who does accept it. Your agent at The Modern Medicare Agency can quickly find nearby providers who accept assignment and match your plan.
Recent Changes and Trends
Medicare excess charges and related rules have seen targeted state and federal shifts. These changes affect when providers can bill above Medicare’s approved amount and which plans can protect you from those extra fees.
Policy Updates Impacting Excess Charges
Several states now limit or ban Part B excess charges. If you live in Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, providers cannot bill you the extra 15% above Medicare’s approved amount in most cases.
That law directly lowers your out-of-pocket risk when you see non‑assignment providers. At the federal level, regulators have focused on clearer billing notices and claim processing rules so beneficiaries get correct error-free statements.
You should check your state rules first, then confirm with any provider whether they accept Medicare assignment. If you have a Medigap Plan F or G, verify whether your plan still covers excess charges and whether you remain eligible.
Outlook for Future Legislation
Lawmakers have discussed expanding protections against excess charges in additional states and at the federal level. Proposals aim to require clearer patient disclosures when providers don’t accept assignment and to explore limits on how often providers can bill excess amounts.
These efforts could reduce surprise bills for outpatient services. You should watch state legislatures and Congress for bills that affect your rights.
If new protections pass in your state, you may no longer face the 15% surcharge from non‑assignment providers. For personal guidance on how upcoming changes may affect your plan choices, contact The Modern Medicare Agency.
Our licensed agents are real people you can speak to one‑on‑one. They will match Medicare packages to your needs without extra fees that break the bank.
Common Misconceptions About Medicare Excess Charges
Medicare excess charges only apply when a provider does not accept Medicare assignment and can be up to 15% above the Medicare-approved amount. You can avoid them by choosing providers who accept assignment or by using certain Medigap plans that cover excess charges.
Overestimating Frequency of Excess Charges
Many people think excess charges happen at most visits, but they are actually limited to situations where a provider does not accept Medicare assignment. Most primary care doctors and large health systems accept assignment, so you will rarely see excess charges there.
Specialists and small private practices are more likely to decline assignment. You should check a provider’s status before an appointment.
Ask directly, “Do you accept Medicare assignment?” or use Medicare’s online tools. If you have Medigap Plan F or G (subject to eligibility), those plans can help cover excess charges, reducing your out-of-pocket risk.
Beliefs About Universal Charges Across States
Some believe excess charges vary by state rule, but federal law caps them at 15% above the Medicare-approved amount for providers who don’t accept assignment.
States cannot raise that federal cap, though a provider in any state may choose not to accept assignment and charge up to that limit.
You still face local differences in how often providers refuse assignment.
Rural areas and specialty clinics can show higher rates of non-assignment.
