What Is the Medicare Limiting Charge?
Short answer
The Medicare limiting charge is the maximum amount many nonparticipating Original Medicare providers may charge above Medicare’s nonparticipating approved amount for certain covered Part B services when they do not accept assignment.
Coverage
The rule protects beneficiaries from unlimited billing by enrolled nonparticipating providers for services subject to the limiting charge.
Not Automatic
The limiting charge does not apply to every item, supplier, noncovered service or private contract, and opted-out clinicians follow different rules.
Costs And Ma
State law can sometimes provide additional protections. Medicare Advantage out-of-network billing follows different plan rules.
Practical Example
A nonparticipating physician who declines assignment cannot simply bill any amount desired when the service is subject to Medicare’s limiting-charge rule.
Questions to verify
- Is the provider enrolled and nonparticipating?
- Does the limiting charge apply to this service?
- Does state law provide stronger protection?