Your Medicare Benefits: What Is the Limiting Charge?

When you visit a doctor or provider that accepts assignment, you know that they are contracted with Medicare to accept the Medicare-approved amount for a particular service as full payment. If you choose to go to a physician or supplier that does not accept assignment, there are a few things you should know.

If your doctor doesn’t accept assignment, they may charge you more than the Medicare-approved amount for a service. However, there’s a limit called “the limiting charge,” which means the provider can’t charge more than 15% over the Medicare approved amount for non-participating providers.

The limiting charge applies only to certain services and doesn’t apply to some supplies and durable medical equipment (DME). When getting certain supplies and DME, Medicare will only pay for them from suppliers enrolled in Medicare, no matter who submits the claim (you or your supplier).

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

If you disagree with a Medicare coverage or payment decision, you have the right to appeal. For information on how to file an appeal, see your Medicare & You handbook, or visit Medicare.gov/appeals.