Understanding Medicare Limiting Charges: Key Factors and Their Implications

Introduction: Medicare Limiting Charges Explained

Medicare's limiting charge rule plays a pivotal role in protecting beneficiaries from excessive costs. It acts as a safeguard, capping the amount a healthcare provider can charge for certain services. However, this rule is often misunderstood, leading to unanticipated expenses. This comprehensive guide is here to simplify Medicare limiting charges and show you how they apply in different scenarios.

What are Medicare Limiting Charges? 

Medicare limiting charges are additional fees that certain healthcare providers can levy above and beyond the Medicare-approved amount for specific services. These providers are non-participating providers who have not "accepted assignment," meaning they haven't agreed to accept the Medicare-approved amount as full payment[[1]

The limiting charge serves as a cap to protect Medicare beneficiaries—it restricts providers from charging more than 15% over the Medicare-approved amount[[1] [2]

When do Medicare Limiting Charges Apply?

Medicare limiting charges apply when your healthcare provider does not accept Medicare assignment. In these cases, you may have to pay the full service amount at the time of service, and your provider can charge up to 15% over the Medicare-approved amount[[1]

It's worth noting, however, that providers who "opt-out" of Medicare altogether are not subject to the limiting charge rule. Therefore, services rendered by these providers can lead to higher out-of-pocket expenses[[1]

Medicare Limiting Charges and Concierge Care

In the world of concierge medicine, Medicare limiting charges also play a role. Despite Medicare not covering concierge care membership fees, doctors within this sphere must still comply with Medicare rules. This compliance includes abiding by the limiting charge rule if they don't accept assignment[[2]

Frequently Asked Questions About Medicare Limiting Charges

What happens if my provider accepts Medicare assignment?

When your provider accepts assignment, they agree to take the Medicare-approved amount as full payment for services. In these cases, your out-of-pocket costs may be lower, and the provider can only charge you for the Medicare deductible and coinsurance amount. These providers cannot add a limiting charge[[1]

Are all services subject to Medicare limiting charges?

No, not all services are subject to Medicare limiting charges. The limiting charges only apply to certain Medicare Part B services, not Part A services.

How can I find out if my provider accepts assignment?

Most providers accept assignment for all Medicare-covered Part A and Part B services. However, it's always best to confirm with your healthcare provider or contact Medicare directly for this information.

Conclusion: Navigating Medicare Limiting Charges 

Understanding the nuances of Medicare limiting charges can be challenging, but it's crucial to making informed decisions about your healthcare. Keep in mind that these charges apply only when a healthcare provider doesn't accept assignment. Thus, always confirm whether your provider accepts assignment to manage your out-of-pocket expenses effectively. Remember, you have a right to quality, affordable healthcare—don't hesitate to ask questions or seek clarification on any aspects that seem confusing. Knowledge is power when it comes to navigating the complexities of the Medicare system.


[[1]    Does your provider accept Medicare as full payment? | Medicare

[[2]  Concierge Medicine Coverage (medicare.gov)