Medicare Part B excess charges are any costs higher than those approved by Medicare. A person is usually required to settle these costs themselves, but help may be available.
Medicare Part B provides coverage for outpatient services, such as visits to a doctor’s office or an appointment with a specialist.
Medicare has set amounts that they will pay for specific treatments and services. If a healthcare provider charges more than the Medicare-approved amount, a person will be required to pay this as an out-of-pocket expense.
Help is available to cover out-of-pocket expenses, and sometimes this includes Part B excess charges.
This article looks at Medicare Part B excess charges and the additional help that may be available.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Part B provides medical coverage for non-hospital visits such as to a primary care physician, specialist, or other healthcare professional.
An individual will typically have to pay out-of-pocket expenses such as deductibles, coinsurances, and copayments for Medicare-covered services.
The list below is a summary of Part B commonly covered services:
- Healthcare provider services: Health services a person receives from a licensed medical professional.
- Durable medical equipment (DME): Purchase or rental of DME, such as a wheelchair or walker, from a Medicare-approved supplier. A doctor must confirm that the item is medically necessary.
- Home health services: Skilled nursing or therapy care if a person is unable to leave home.
- Ambulance services: Emergency transportation, usually to and from a hospital.
- Non-emergency ambulance or ambulette: Transportation when no safe alternative is available for medically necessary treatment or services.
- Preventive services: Screenings and counseling intended to maintain health, prevent illness, and detect health conditions.
- Therapy services: Outpatient services, including speech, physical, and occupational therapy provided by a Medicare-approved therapist.
- Mental health services: Group and family therapies, activity therapies, substance use disorder therapy, and some medications that must be administered by a doctor.
- Limited prescription drugs: Immunosuppressants, cancer drugs, anti-emetic drugs, dialysis drugs, and medications that are administered by a physician.
Diagnostic tests and limited chiropractic care is also usually available with Part B coverage.
Medicare has a pre-approved amount they will pay for eligible treatment and services.
If a person has Medicare Part B, and the amount a physician or healthcare provider charges is higher than the Medicare-approved amount, the difference is called an excess charge.
An individual is responsible for payment of excess charges and these costs do not usually count toward an annual deductible.
Private insurance companies offer Medigap plans, also known as Medicare supplement insurance. Medigap plans aim to fill some of the gaps left by original Medicare’s out-of-pocket expenses.
Some plans even offer additional benefits, including emergency care provided outside the United States, and excess charges.
To be eligible for a Medigap plan, a person must have original Medicare parts A and B.
A separate monthly premium is payable to the private insurance company selling the Medigap plan.
If a person has Medicare Advantage (Medicare Part C), Medigap insurance cannot legally be sold to them.
Other Medigap eligibility requirements may apply, depending on the state in which an individual resides.
Each Medigap policy offers different benefits and levels of coverage.
Monthly premiums may vary depending on:
- the private insurance provider
- the state in which a person lives
- when an individual becomes eligible for Medicare
With these considerations in mind, a person may have up to ten different Medigap policies to compare, including plans A, B, C, D, F, G, K, L, M, and N.
It is important to note that Medigap policies in the states of Massachusetts, Minnesota, and Wisconsin are standardized differently, meaning the plans offered may differ from those available in other states and may also be subject to different rules.
Medigap plans F and G may cover Part B excess charges. High-deductible versions of both of these plans are available in some states.
However, as of January 1, 2020, plan F is not available to those newly eligible for Medicare. Medigap policies that provided coverage for the Part B deductible are also no longer available for new enrollees as of January 1, 2020.
If a person needs help choosing a Medigap policy, they can contact their State Health Insurance Assistance Program (SHIP).
For more information on state Medigap policies, an individual can contact the State Department of Insurance.
Excess charges are treatment or service costs that exceed Medicare-approved amounts.
Some Medigap policies cover Medicare Part B excess charges, and a person can compare plans to choose the most suitable coverage for their needs.
Private insurance companies offer Medigap policies, and, as such, benefits may vary. There may also be different benefits and rules according to the state in which a person lives.