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What are Medigap Excess Charges

Written by Brian Gruss

While shopping for Medigap plans something you may have noticed is that several of the plans cover something called Medicare Part B Excess Charges. What are Medigap Excess charges, also known as Medicare Part B Excess Charges? If you don’t know what these excess charges are you are in good company. Thankfully, for most Medicare beneficiaries this is not something that occurs very often. However, it is important to know how Medicare Part B works and how the excess charges can impact yours out of pocket healthcare expenses.

Defining the Medicare Part B Excess Charges

Healthcare professionals can choose whether or not they participate in Medicare. If the doctors participate with Medicare, they agree to charge you only the approved Medicare amounts for their services and procedures. Basically, they agree to accept that the Medicare set amount will make the procedure “paid in full”. Doctors and healthcare professionals also call this accepting Medicare assignment.

Doctors who accept Medicare assignment are essentially agreeing not to bill you above the Medicare allowable rate for any service you receive. If a provider chooses not to participate in Medicare, they can then bill you up to 15% more than the Medicare allowable charge for the procedure or service. The additional amount, up to 15% above the allowable charges, is considered Medicare Part B excess charges. You will be expected to pay this amount in addition to any other fees and charges allowed by Medicare. All Medigap plan F & G offer coverage that includes the Part B excess charges and will save you money if you need to see a provider who does not participate in Medicare.

What’s the Advantage

Choosing a Medicare participating provider does give you other advantages.  Most likely they will not charge you up front. They will only request the agreed Part B Deductible or coinsurance amounts at your appointment time. Before they bill you, they will wait until Medicare, and your Medigap plan has paid their portion of the bill. They have to submit your claim to Medicare for you and with no cost to you. Non participating providers may not bill Medicare and can make you pay upfront for all services and submit the receipts for reimbursement.

Many primary care providers do accept Medicare assignment, so you may never encounter a situation where you are responsible for a Medicare Part B excess charge. Specialists are more likely to not take the Medicare assignment and enforce Part B excess charges.

There is no set dollar limit or limit on the number of times a Part B excess charge can be added to your bill. If you choose to see a doctor regularly who do not accept Medicare assignment you could easily be paying hundreds of dollars in excess charges each year.

How to avoid Excess Charges

The simplest way to avoid paying Medicare Part B excess charges is only to use service providers who accept Medicare assignment. This will ensure that you will never be charged more than the Medicare allowable charge for your appointments and procedures. Make sure you double check with your doctor before you make an appointment. This advise holds true for any additional providers or facilities like home health care companies, durable equipment, lab work, etc. You can always use the medicare.gov website and locate providers that way.

Another way to avoid paying any excess charges is to purchase a Medigap plan that pays all of them for you. Medigap plans F and G both include this benefit and can bring great peace of mind.

State Laws

Some states have different laws for Medicare and the companies and physicians billing Medicare. Connecticut, Massachusetts, New York, Ohio, Pennsylvania, Rhode Island and Vermont have passed laws that do not allow any health care professionals from charging Medicare patients more than the approved allowable rates set by Medicare. If you live in one of these states and are interested in a Medigap plan, a Plan N might be a great fit. The benefits of a Plan N are similar to a Plan G, but one big difference is that Plan N excludes excess charges, but typically has a lower premium. If you live in a state that does not allow excess charges, a plan N could save you additional money!

*** But, remember, if you use your coverage out of state you need to do your research as the Plan N would not shield you from excess charges like a Plan G or Plan F out of state. ***

If you have more questions about Medicare Part B Excess Charges or are interested in learning about how to customize your Medicare coverages to meet your individual needs, we would love to help you! 352-508-4221

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About Just Medigap

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