Medicare Assignment and the Part B Excess Charge

Medicare Assignment

When a provider accepts Medicare Assignment, they agree not to charge more than the Medicare-approved amount for covered services. The Medicare-approved amount is the payment rate Medicare sets for services under Original Medicare. Always ask your provider if they accept Medicare Assignment before receiving services.

Participating Providers

Participating providers accept Medicare Assignment for all covered services and agree to:

• Accept the Medicare-approved amount as full payment

• Receive payment directly from Medicare

• Not bill you for any amount beyond the applicable Medicare deductible and coinsurance

Non-Participating Providers

Non-participating providers accept Medicare but don't accept Medicare Assignment for all services. However, they must accept assignment for some services, such as Medicare-covered ambulance services. In those cases, you are responsible only for the applicable deductibles and coinsurance.

If you choose to see a non-participating provider:

• They may charge an Excess Charge of up to 15% more than the Medicare-approved amount.

• You may be required to pay the full amount at the time of service.

• They may or may not file the claim with Medicare.

Note: If the provider doesn't file the claim, you must file the claim with Medicare and with your Medicare Supplement Insurance (Medigap) plan, if you have one.

Medicare Part B Excess Charge

The Medicare Part B excess charge is the additional amount a provider may bill when they do not accept Medicare Assignment. Non-participating providers may charge up to 15% above the Medicare Part B approved amount. Some Medigap plans cover excess charges, while others don't. The plans that cover excess charges include Plan F and Plan G. Their high-deductible versions cover them as well, but only after the deductible is met.

Example:

• Medicare approves a $100 service. 

• The provider doesn't accept assignment and charges an additional 15%.

• Medicare pays the first $100 of the service charge.

• You would pay the $15 excess charge out of pocket.
  

State Rules

Certain states prohibit healthcare providers from billing Medicare Part B excess charges. These states are:

• Connecticut

• Massachusetts

• Minnesota

• New York

• Ohio

• Pennsylvania

• Rhode Island

• Vermont
  

If you live in one of these states, providers can't charge you Part B excess fees when you are within your state. However, you may still be charged excess fees if you receive care outside of your state from a provider who doesn't accept Medicare Assignment. 

Additional Information

• Connecticut: CT doesn't allow Part B excess charges for participants enrolled in the QMB program but does allow excess charges for other participants.

• Minnesota: MN does not allow Part B excess charges for its own citizens, but providers may charge excess fees to those coming from other states to use Minnesota facilities, such as the Mayo Clinic.

• New York: Providers in NY may charge up to 5% over the Medicare-approved amount, also referred to as Balance Billing. Services that aren't included in the state law, like certain home and office visits involving evaluation and management services, are capped by federal law at no more than 15% over Medicare’s approved payment amount.