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Individuals enrolled in Original Medicare probably have a pretty good understanding of Medicare Part B and what it covers. Many Medicare beneficiaries are surprised when they receive an unexpected bill; these unexpected costs may come from excess charges. Some of you may not have heard of excess charges. We will answer the question; What are Part B excess charges and hopefully help some of you avoid them.

Medicare Part B Excess Charges

Medicare Part B excess charges occur when a doctor or healthcare provider does not accept Medicare assignment and charges more than the Medicare-approved amount for a covered service.

Here’s how it works:

• Medicare sets an “approved amount” for every Part B service.
• Doctors who accept Medicare assignment agree to accept this amount as payment-in-full.
• Providers who don’t accept assignment can charge up to 15% over the Medicare-approved rate.
• The extra 15% is called an excess charge; the beneficiary must pay that amount out of pocket, unless they have supplemental coverage that pays it.

Example of a Part B Excess Charge

Let’s say a beneficiary has met his annual deductible and receives a procedure from his doctor; the Medicare-approved amount for the procedure is $200.

• If the doctor accepts assignment, they’ll charge $200. Medicare pays 80% of the cost ($160). The beneficiary pays the remaining 20% ($40).
• If the doctor does not accept assignment, they can charge up to 15% more: $200 + $30 = $230. Medicare will still pay 80% of the approved $200 ($160), but the beneficiary owes not only their 20% ($40) they also have to pay the excess charge of $30, therefore their total out-of-pocket cost is $70.

When Do Excess Charges Apply

Excess charges only apply to Medicare Part B services and only when:

1. It is a service that Part B covers.
2. The provider does not accept Medicare assignment.
3. The provider charges more than the Medicare-approved amount.

Important: Not all states allow excess charges. For example, Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont have laws that prohibit excess charges for Medicare beneficiaries.

How to Avoid Excess Charges

1. Use Participating Medicare Providers
   Always ask the provider if they accept Medicare assignment before receiving care. This ensures the beneficiary does not pay more than the Medicare-approved amount.
2. Consider a Medicare Supplement Plan (Medigap)
   Individuals who are worried about excess charges, consider a Medigap Plan. The Plan G or Plan F (if you were eligible before 2020) both cover 100% of Medicare Part B excess charges. This provides protection from surprise bills.
3. Check State Rules
   Those who live in states that bans excess charges don’t need to worry about them; providers in those states can’t legally charge more than the Medicare-approved rate.

Unfortunately, some agents or beneficiaries overlook Medicare Part B excess charges when discussing Medicare coverage. That cost can surprise even savvy Medicare beneficiaries. However, with the right knowledge and the right plan, beneficiaries can avoid them altogether.

Click here to watch a quick YouTube video on Medicare Enrollment Periods

Please note; It is important to verify the provider accepts Medicare assignment and beneficiaries may want to consider supplemental coverage for full protection.

Medicare Excess Charges Connecticut

Medicare Excess Charges Connecticut:    Medicare excess charges or sometimes called excess billing is applied by doctors that do not accept Medicare assignment.  A doctor who chooses not to accept assignment is able to bill a patient 15% over the allowable Medicare charges.  However, Those providers are not able to bill over Medicare allowable limit on all charges.  Some items that providers cannot use the excess charge on include Durable Medical Equipment. This is true even if they are not accepting assignment.   Non par is another way of saying that the doctor does not have to accept the Medicare contracted price for services.   You should not confuse Non par with a Medicare opt out.  An opt out is when a doctor does not participate with Medicare.   Medicare will not provide any coverage for services rendered by an opted out physician or facility.

Be very careful when you ask a provider if they “take” your insurance!

You might think, if the provider says that they “take”  your insurance they participate with your insurance carrier.  This is not always the case. This only confirms that they will accept payment from your insurance company and they may submit your claim for you.  It does always not mean that they  have a contract with your carrier.

If you want to be sure, you should always ask healthcare providers if they are contracted as a participating provider with your insurance carrier.  Unfortunately, there are some providers out there who will mislead you with their wording in order to get your business.  This is more common than you would think. For this reason you must ask the right questions to avoid costly situations.  Your carrier cannot protect you from any carrier they do not have a contract with.

Fortunately, Connecticut does not allow excess charges or billing from doctors that are non par.  Some Medicare supplement plans cover excess charges.    That benefit is not necessary in CT and should not factor into deciding which plan you should choose.

Click here to access the government site on Medicare.

If you have questions or need additional information regarding your current or future Medicare needs, call the office at 203-796-5403 or email us at admin@croweandassociates.com.  Allow us to use or many years of experience and in-depth knowledge of all Connecticut Medicare plans and providers to help you navigate the Medicare process.