Eight states do not allow Medicare excess charges, or sharply limit them: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont. If you live in one of these states and get care within its borders, a doctor generally cannot bill you more than the Medicare-approved amount for a covered Part B service. In the other 42 states, non-participating providers may legally add up to 15% on top of what Medicare approves, and that difference comes out of your pocket.
What a Medicare Excess Charge Is
When a provider “accepts assignment,” they agree to take the Medicare-approved amount as full payment. You still owe coinsurance and any remaining deductible, but nothing above that. Non-participating providers are different: they treat Medicare patients but reserve the right to bill more than the approved amount on a case-by-case basis.
Federal rules cap that extra billing at 115% of the fee schedule amount for nonparticipating suppliers, a ceiling known as the limiting charge.1eCFR. 42 CFR 414.48 – Limits on Actual Charges of Nonparticipating Suppliers The gap between the Medicare-approved amount and that 15% overage is the excess charge, and it’s yours to pay.2Medicare.gov. Does Your Provider Accept Medicare as Full Payment?
Excess charges only apply to services Medicare Part B covers. Services Medicare excludes entirely, like routine dental work, most vision and hearing exams, and cosmetic procedures, sit outside this framework because there is no Medicare-approved amount to build from.
The Eight States That Restrict Excess Charges
- Connecticut
- Massachusetts
- Minnesota
- New York
- Ohio
- Pennsylvania
- Rhode Island
- Vermont
Most of these states ban excess charges outright, requiring providers to accept the Medicare-approved amount as full payment regardless of participation status. New York uses a slightly different approach, capping excess charges at a lower threshold rather than eliminating them. The financial effect for beneficiaries is broadly similar across all eight.
The Protection Stops at the State Line
The ban applies only to care you receive inside your home state. An Ohio resident who sees a specialist across the line in Indiana is billed under Indiana’s rules, where excess charges are allowed. If you travel for medical care or spend part of the year in another state, confirm assignment before each out-of-state visit.
Opt-Out Providers Are a Separate Category
A small share of physicians has opted out of Medicare entirely. As of 2024, about 1% of non-pediatric doctors had fully opted out, with psychiatrists at roughly 8%. Opt-out providers sign private contracts with individual Medicare patients, and those contracts waive Medicare billing limits.3eCFR. 42 CFR Part 405 Subpart D – Private Contracts
Under a private contract, the doctor can charge any amount, Medicare pays nothing, and the limiting charge does not apply. State excess charge bans generally will not help either, because those laws address the gap between Medicare’s approved amount and a non-participating provider’s bill. With an opt-out provider, there is no Medicare-approved amount in the picture.
One safeguard: a provider cannot ask you to sign a private contract during an emergency. If an opt-out physician treats you in an emergency without a prior contract, they are held to the standard limiting charge for physicians or to the deductible and coinsurance for other practitioners.3eCFR. 42 CFR Part 405 Subpart D – Private Contracts
If You Live in One of the Other 42 States
A Medigap policy is the most common protection. Two standardized plan types cover 100% of Part B excess charges:
- Plan F covers all excess charges but is only available to people who became eligible for Medicare before January 1, 2020.4Medicare.gov. Compare Medigap Plan Benefits
- Plan G also covers 100% of excess charges and is available to everyone. It does not cover the Part B deductible ($283 in 2026).4Medicare.gov. Compare Medigap Plan Benefits
Plan N, another popular Medigap option, does not cover excess charges.4Medicare.gov. Compare Medigap Plan Benefits If you choose Plan N for its lower premium, you’re exposed to the full 15% overage when you see a non-participating provider. That tradeoff matters most in areas where specialists commonly decline assignment.
Plan G monthly premiums ranged roughly from $120 to $220 or more across most states in 2026. A single surgery or a run of specialist visits with a non-participating provider can outweigh the premium difference between plans quickly.
Checking a Provider Before You Book
Ask the office directly whether they accept Medicare assignment for your visit. You can also look up a doctor in Medicare’s provider directory at Medicare.gov, which shows whether the provider is participating, non-participating, or has opted out.
Non-participating providers can accept assignment on a case-by-case basis even if they don’t do so routinely.5Medicare Interactive. Participating, Non-Participating, and Opt-Out Providers Ask the billing office directly before the appointment. Some will agree when a patient raises it.
If You’re Billed an Excess Charge You Shouldn’t Owe
Start with your Medicare Summary Notice, which lists what the provider billed, what Medicare approved, and the maximum you should owe.6Medicare.gov. Medicare Summary Notice (MSN) Compare those figures to the provider’s bill. Any gap between the approved amount and what you were charged is the excess charge.
Call the billing office first. In protected states, staff sometimes are not aware of the restriction, and a straightforward explanation is enough to fix the bill. If it isn’t, contact your State Health Insurance Assistance Program (SHIP) for free counseling.7Administration for Community Living. State Health Insurance Assistance Program (SHIP) SHIP can be reached at 877-839-2675 or through shiphelp.org.
If the provider still won’t correct the charge, file a complaint with your state’s Department of Insurance or the equivalent regulator. Those agencies enforce the state laws restricting excess charges. For general Medicare billing questions, call 1-800-MEDICARE (1-800-633-4227).8Medicare.gov. Contact Medicare