You went to the doctor, paid your 20% coinsurance, and thought you were done. But then a bill arrives for an additional 15% charge. You call Medicare, and they tell you, "Sorry, that is legal."
This is called a Medicare Part B Excess Charge. While many doctors accept Medicare's standard rates, some do not—and they are allowed by federal law to bill you extra.
In 2026, as more doctors struggle with reimbursement rates, opting to become "Non-Participating" providers is a growing trend. Here is how to spot this trap and protect your wallet.
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| Doctor Charged You 15% Extra? |
1. What Are "Excess Charges"?
There are two types of doctors who treat Medicare patients:
- Participating Providers: They "Accept Assignment," meaning they accept the Medicare-approved amount as payment in full. (You pay 20%, Medicare pays 80%).
- Non-Participating Providers: They accept Medicare patients but do not agree to the standard prices. They can legally charge you up to 15% more than their allowable rate.
The Real Math (It's Tricky): Medicare actually pays these doctors 95% of the standard rate. They can then add 15% on top of that.
Example: If a procedure is standardly $1,000, a non-participating doctor's max charge is roughly $1,092.50. Medicare pays their share, but YOU are responsible for the entire difference (the excess) plus your standard 20% coinsurance.
2. Does Your Insurance Cover This?
This depends entirely on your supplemental coverage (Medigap). Note that the Part B Deductible is $283 in 2026, which you must pay first.
| Plan Type | Excess Charge Coverage |
|---|---|
| Medigap Plan G | 100% Covered. (Best Option) |
| Medigap Plan N | 0% Covered. You pay the bill. |
| Medicare Advantage | Varies. Out-of-network doctors may balance bill you. |
3. The "MOM" States Exception
If you live in one of these states, you are lucky. State laws (Medicare Overcharge Measures) prohibit or limit these charges:
Connecticut, Massachusetts, Minnesota, Ohio, Pennsylvania, Rhode Island, and Vermont.
*Special Note for New York: Doctors can charge excess, but it is capped at 5% instead of 15%.
4. The Magic Question to Ask
To avoid this bill, never assume. When booking an appointment with a new specialist or surgeon, ask this exact question:
"Does this doctor accept Medicare Assignment?"
If they say "We accept Medicare" but hesitate on "Assignment," they might be a Non-Participating provider. Clarify before you go.
5. Verdict: Check Your Card
A 15% surcharge might not sound like much on a $100 office visit, but on a $20,000 surgery, it is a $3,000 surprise you didn't budget for.
Check your Medigap card today. If you have Plan N, be vigilant about which doctors you see. If you have Plan G, relax—you are fully covered.
Disclaimer: Insurance plans and state laws vary. The 2026 Part B deductible is $283. Always verify coverage with your insurance agent or SHINE counselor.
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