Jack's Blog on Medicare Plan Choices

When Can Providers Charge Above Medicare Approved Rates?

Doctors can charge balance billing up to 15% of the Medicare rate in specific circumstances related to Medicare Part B. This practice is known as “limiting charge” and applies to certain non-participating providers.

“Limiting Charge” refers to the maximum amount that non-participating providers can bill Medicare patients above the Medicare-approved amount for certain services. Here are the key points:

Purpose: It’s designed to protect Medicare beneficiaries from excessive out-of-pocket costs while allowing some flexibility for providers.

Definition: It’s the highest amount a non-participating provider can charge a Medicare beneficiary for covered services.

Amount: The limiting charge is set at 15% above the Medicare-approved amount for services.

Applies to: Non-participating providers who don’t accept Medicare assignment for all services.

Scope: Only applies to services covered under Medicare Part B (medical insurance).

Your responsibility: The beneficiary is responsible for paying this additional amount, on top of their regular cost-sharing.

Not universal: This charge doesn’t apply to all Medicare services or all providers.

State variations: Some states have laws that restrict charges even further.

• Connecticut: Limits charges to 5% over the Medicare-approved amount.
• Massachusetts: Prohibits any balance billing above Medicare-approved amounts.
• Minnesota: Restricts charges to the Medicare-approved amount for most services. New York: Limits charges to 5% over the Medicare-approved amount.
• Pennsylvania: Prohibits balance billing for Medicare-covered physician services.
• Rhode Island: Restricts charges to the Medicare-approved amount.
• Vermont: Prohibits balance billing for most Medicare-covered services.

Before choosing an Advantage or Supplement plan, ensure you have a thorough understanding of Medicare itself. When it’s time to explore your options, don’t fall for a sales pitch from a single company or an agent representing only one provider.

At “More Plans More Choices,” I can provide you with side-by-side comparisons from various insurance carriers. More carriers plus more plans equals more choices.

Call me toll free at (888) 883-6074