What is a limiting charge in Medicare?

A "limiting charge" in Medicare refers to the maximum amount that non-participating healthcare providers can charge for a covered service. Non-participating providers are healthcare providers who do not accept assignment on a Medicare claim, meaning they do not agree to accept Medicare's approved amount as payment in full. Under Medicare, participating providers are required to accept Medicare's approved amount as payment in full for covered services. However, non-participating providers can charge up to 15% more than the Medicare-approved amount for their services. This additional 15% charge is called the "limiting charge".

1. For example, if the Medicare-approved amount for a covered service is $100, a non-participating provider can charge up to $115 for that service. Medicare will still pay its portion of the approved amount ($80), and the beneficiary will be responsible for paying the remaining $35 (which includes the $15 limiting charge).

2. It's important to note that the limiting charge only applies to certain Medicare services, such as doctor's services, outpatient therapy, and durable medical equipment. It does not apply to services provided by hospitals or other facilities.

3. Additionally, some states have laws that limit the amount that non-participating providers can charge for Medicare services. In these states, the limiting charge may be lower than 15%.

4. The limiting charge is an important consideration for Medicare beneficiaries who receive services from non-participating providers. Before receiving services from a non-participating provider, it's important to understand the costs and potential out-of-pocket expenses associated with the limiting charge.

MedHelpCenter.us recommends that you call the Senior Health Insurance Agency at 813-592-8568 for further help and explanation.