A Medicare Part B excess charge is the extra amount a doctor who does not accept Medicare assignment can bill you, on top of your normal 20% coinsurance. Federal law caps it at 15% above the Medicare-approved amount for that doctor (the "limiting charge"). Eight states ban or limit excess charges further: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont. Excess charges are rare, because almost every doctor takes assignment. They matter most when choosing a Medigap policy: Plans F and G pay excess charges, and Plan N does not.
This page explains how the charge is calculated, what it costs in real dollars, what each of the eight states does, and how to decide whether the risk is worth paying for. The rule has been the same for decades and is in force for 2026 and 2027. Dollar examples use 2026 figures, because CMS had not published the 2027 Part B deductible as of this writing.
How Part B Excess Charges Work
Every doctor and practitioner who bills Original Medicare falls into one of three groups. Which group your doctor is in decides whether an excess charge is possible.
| Provider type | Accepts the Medicare-approved amount? | What you pay (after the Part B deductible) | Excess charge possible? |
|---|
| Participating (accepts assignment) | Always | 20% coinsurance | No |
| Non-participating | Sometimes, claim by claim | 20% of a lower approved amount, plus up to 15% more if they do not take assignment on that claim | Yes, up to the limiting charge |
| Opted out of Medicare | Never | The full price in a private contract. Medicare pays nothing except in emergencies | No federal cap at all |
Medicare.gov describes the cap this way: for a provider who does not accept assignment, "the charge can't be more than 15% above the Medicare-approved amount," and it calls that ceiling the limiting charge. "Excess charge" is the industry term for the part of the bill between the approved amount and that ceiling.
The math behind the 15%
The 15% is not measured against what a participating doctor gets. CMS pays non-participating providers 95% of the regular fee schedule amount. The limiting charge is 115% of that lower amount. So the most a non-participating doctor can bill is 109.25% of what a participating doctor would be paid for the same service (95% x 115%). CMS's own billing example uses a $100 fee schedule amount: the non-participating amount is $95.00, and the limiting charge is $109.25.
What Excess Charges Cost: Worked Examples
These examples assume you have already met the 2026 Part B deductible of $283 and have no supplemental coverage. Fee schedule amounts are illustrative; real amounts vary by service and area.
Example 1: A specialist visit with a $200 fee schedule amount
| Participating doctor | Non-participating doctor, no assignment |
|---|
| Medicare-approved amount | $200.00 | $190.00 (95%) |
| Most the doctor can bill | $200.00 | $218.50 (115% of $190) |
| Medicare pays (80%) | $160.00 | $152.00 |
| Your 20% coinsurance | $40.00 | $38.00 |
| Excess charge | $0 | $28.50 |
| Your total | $40.00 | $66.50 |
Example 2: An outpatient surgery with a $2,000 fee schedule amount
| Participating doctor | Non-participating doctor, no assignment |
|---|
| Medicare-approved amount | $2,000 | $1,900 |
| Most the doctor can bill | $2,000 | $2,185 |
| Medicare pays (80%) | $1,600 | $1,520 |
| Your 20% coinsurance | $400 | $380 |
| Excess charge | $0 | $285 |
| Your total | $400 | $665 |
The excess charge on any one bill is limited. The risk is that Original Medicare has no yearly out-of-pocket maximum, so excess charges on a long course of treatment from a non-participating specialist can keep adding up. A non-participating provider who does not take assignment can also ask you to pay the whole bill up front, then Medicare sends its share to you.
How common are they?
Not very. KFF reports that virtually all non-pediatric physicians participate in Medicare, and cites MedPAC's estimate that 99.7% of Medicare claims in 2023 were accepted on assignment. About 1% of non-pediatric physicians formally opted out of Medicare in 2024, with psychiatry the specialty most likely to opt out. So for most people, an excess charge is an occasional event tied to one specific provider, not a routine cost.
Two gaps the 15% cap does not cover
- Medical equipment suppliers. The limiting charge is set for physician fee schedule services. It does not cap what a durable medical equipment supplier that does not take assignment can charge. Medicare's supplier directory at medicare.gov/medical-equipment-suppliers lets you find suppliers that accept assignment.
- Opt-out providers. If you sign a private contract with a provider who has opted out, Medicare pays nothing for that care (except emergencies), no 15% limit applies, and Medigap will not pay either.
The 8 States That Ban or Limit Excess Charges
Eight states have their own laws that go further than the federal 15% cap. The rules are not identical, so the table shows what each state's law does.
| State | What the state rule does | Primary source |
|---|
| Connecticut | Widely listed as a state that bars excess charges. We could not confirm the exact statute, so check details with Connecticut's SHIP | Confirm with your SHIP |
| Massachusetts | Doctors who treat Medicare patients must accept the Medicare-approved amount as a condition of their state medical license | Mass. Acts of 1985, ch. 475; upheld in Massachusetts Medical Society v. Dukakis (1st Cir. 1987) |
| Minnesota | Providers may not charge a Minnesota resident on Medicare more than the Medicare-approved amount. Ambulance services and medical supplies and equipment are excluded | Minn. Stat. 62J.25 |
| New York | Physicians may charge no more than 105% of the Medicare amount for most services (a 5% cap instead of 15%). Office and home visits stay under the federal 15% limit | N.Y. Public Health Law section 19 |
| Ohio | "No health care practitioner ... shall balance bill" a Medicare beneficiary. Deductibles and coinsurance are still owed | Ohio Rev. Code 4769.02 |
| Pennsylvania | Balance billing Medicare patients by health care practitioners is prohibited, and practitioners must post a notice of your rights | 35 P.S. 449.34 (Medicare Fee Control Act) |
| Rhode Island | Widely listed as a state that bars excess charges. Physicians must also tell Medicare patients in advance whether they accept assignment | R.I. Gen. Laws 5-37-22 (disclosure); confirm the charge rule with your SHIP |
| Vermont | A physician who agrees to treat a Medicare beneficiary may not balance bill, except in narrow cases listed in the law | 33 V.S.A. chapter 65 |
Three points about these laws:
- Where the care happens matters. A state law generally protects care delivered in that state. If you live in Ohio and see a specialist in Kentucky, the federal 15% cap applies to that bill, not Ohio's ban. Minnesota's law is written for Minnesota residents.
- New York is a limit, not a full ban. A non-participating New York doctor can still bill up to 5% extra on most services, and up to 15% extra on office and home visits.
- Exceptions exist. Minnesota excludes ambulances and medical equipment, and none of these laws turn an opt-out doctor's private contract into a Medicare claim. Your State Health Insurance Assistance Program (SHIP) gives free counseling and can confirm how your state's law applies to a specific bill.
Excess Charges and Plan G vs Plan N
This is where excess charges matter most. Medigap policies are standardized by letter in most states, and only two letters pay Part B excess charges.
| Medigap plan | Pays Part B excess charges? | Who can buy it |
|---|
| Plan F (and high-deductible F) | Yes, 100% | Only people eligible for Medicare before January 1, 2020 |
| Plan G (and high-deductible G) | Yes, 100% | Anyone in the Medigap market |
| Plan N | No | Anyone in the Medigap market |
| Plans A, B, C, D, K, L, M | No | C is limited to people eligible before 2020 |
Plan G and Plan N cover most of the same things. The differences are that Plan N has copays of up to $20 for some office visits and up to $50 for emergency room visits that do not lead to an admission, and Plan N does not pay excess charges. In exchange, Plan N usually has a lower monthly premium. Our Plan N cost and copay guide and Plan G cost guide show real premiums from official state rate guides.
How the state you live in changes the answer
- Connecticut, Ohio, Pennsylvania, Rhode Island and Vermont: with excess charges banned for care in the state, the excess-charge part of Plan G's coverage has little value for care you get at home. The comparison comes down to premiums versus Plan N's copays. It still matters if you often get care in another state.
- New York: the gap shrinks but does not disappear. Excess charges are capped at 5% on most services and 15% on office and home visits.
- Massachusetts and Minnesota: these states (along with Wisconsin) use their own Medigap plan designs instead of the standard lettered plans, so the Plan G vs Plan N choice does not apply in the same form. Compare the state's own plan options instead.
- The other 42 states and DC: the federal 15% limiting charge applies. Plan N's exposure is real but usually small, given how few claims are non-assigned.
A simple way to frame it: Plan N's yearly premium savings compared with Plan G is a known amount. The excess charges you might owe on Plan N are an unknown amount that you control by choosing doctors who accept assignment. If you already see a non-participating specialist regularly, or you spend months each year in another state, the excess-charge coverage in Plan G has more value. For every lettered plan side by side, see our Medigap comparison chart.
How to Avoid Part B Excess Charges
- Ask before the appointment. The exact question is: "Do you accept Medicare assignment?" "We take Medicare" can mean a non-participating provider who bills up to the limiting charge.
- Check Medicare's Care Compare tool. Search for the doctor at medicare.gov/care-compare. Provider listings show whether the provider accepts the Medicare-approved amount. Our guide to finding doctors who accept assignment walks through it.
- Ask about referrals. When a doctor sends you to a specialist, lab or imaging center, ask whether that provider takes assignment.
- Check your Medicare Summary Notice. The notice lists the approved amount and what the provider may bill you. Compare it with any bill you receive.
- Do not pay more than the limiting charge. A non-participating provider who bills above the limit must refund the difference. If a bill looks too high, call 1-800-MEDICARE (1-800-633-4227) or your SHIP.
- Get DME from an assignment-accepting supplier. The 15% cap does not protect you for equipment and supplies.
If you are in the QMB program
People enrolled in the Qualified Medicare Beneficiary (QMB) program, a Medicare Savings Program with income and asset limits set by each state, are protected from more than excess charges. Medicare providers may not bill a QMB enrollee for Medicare deductibles, coinsurance or copays at all. See our guide to Medicare Savings Program income limits to check whether you qualify.
Medicare Advantage is different
Excess charges are an Original Medicare issue. In a Medicare Advantage plan, you pay the plan's copays and coinsurance, and network rules decide what you owe. Out-of-network costs in an Advantage PPO are set by the plan, so read its Evidence of Coverage instead.
Frequently Asked Questions
What is a Medicare Part B excess charge?
It is the difference between the Medicare-approved amount and what a non-participating provider who does not accept assignment bills you, up to a federal cap of 15% above that provider's approved amount. You pay it on top of your 20% coinsurance.
How much can a Part B excess charge be?
Up to 15% of the non-participating approved amount. Because that approved amount is 95% of the regular rate, the most a non-participating doctor can bill is 109.25% of what a participating doctor would be paid. On a $2,000 service, that is up to $285 in excess charges.
Which states don't allow Medicare excess charges?
Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island and Vermont have laws that ban or limit them. New York caps them at 5% for most services rather than banning them, and Minnesota excludes ambulances and medical equipment.
Do excess charges count toward the Part B deductible?
No. Only Medicare-approved amounts count toward the Part B deductible ($283 in 2026). The excess charge is outside the approved amount, so it never counts toward the deductible.
Does Plan G cover excess charges?
Yes. Plan G pays 100% of Part B excess charges, as does Plan F for people eligible for Medicare before January 1, 2020. Plan N and the other lettered plans do not.
If I live in a ban state, do I need Plan G for excess charges?
For care you get inside that state, excess charges are banned or limited, so that part of Plan G's coverage has little value there. It can still matter for care in other states, and in New York, where a 5% to 15% charge is still allowed. Massachusetts and Minnesota do not sell the standard lettered plans.
Can a doctor charge more than the limiting charge?
No. A non-participating provider who bills above the limiting charge must refund the overage. A provider who has opted out of Medicare is different: Medicare does not pay, no limit applies, and you sign a private contract first.
Are excess charges common?
No. MedPAC estimates 99.7% of Medicare claims in 2023 were accepted on assignment, according to KFF. Excess charges usually come from a few specific providers, most often specialists, and you can avoid them by asking about assignment before you book.
Sources
- Medicare.gov, "Does your provider accept Medicare as full payment?" (limiting charge, opt-out providers)
- CMS Medicare Claims Processing transmittals (non-participating 95% rate; limiting charge 115%, $100 to $109.25 example)
- CMS, "2026 Medicare Parts A & B Premiums and Deductibles" fact sheet ($283 Part B deductible)
- KFF, "What to Know About How Medicare Pays Physicians" (October 7, 2025)
- Medicare.gov, "Compare Medigap plan benefits" and "Choosing a Medigap Policy" (Plans F and G and excess charges)
- State laws: Mass. Acts of 1985 ch. 475; Minn. Stat. 62J.25; N.Y. Public Health Law section 19; Ohio Rev. Code 4769.02; 35 P.S. 449.34; R.I. Gen. Laws 5-37-22; 33 V.S.A. chapter 65
