13-05-2025
Medicare Nonparticipating Providers: What You Should Know
A Medicare nonparticipating provider is a healthcare professional, facility, or supplier that doesn't accept Medicare assignment in all cases and may charge more than the Medicare-approved amount for certain services.
When a healthcare professional accepts Medicare assignment, it means they agree to charge the Medicare-approved amount for all medically necessary services.
Nonparticipating providers don't agree to these terms. While they still accept payment from Medicare, they may charge more for covered services.
As a Medicare enrollee, receiving healthcare services from a nonparticipating provider has certain drawbacks. Learn more about what nonparticipating providers are and what to consider when getting care.
Understanding Medicare assignment
For Medicare billing purposes, there are three primary types of healthcare professionals:
participating providers who accept Medicare assignment
nonparticipating providers
opt-out providers
When a healthcare professional, facility, or equipment supplier 'accepts assignment,' it means they agree to charge the Medicare-approved amount for all services covered by Original Medicare (Part A and Part B). These providers can only bill Medicare enrollees for the deductible and coinsurance amounts.
On the other end of the spectrum are opt-out providers. These providers don't participate in Medicare at all. If you receive services from a provider who opts out of Medicare, you must pay the full cost — except in emergencies.
Nonparticipating providers are the middle ground. They may accept assignment in some cases, but they may also charge more than the Medicare-approved amount.
Medicare nonparticipating providers
Medicare nonparticipating providers can decide whether to accept the Medicare-approved amount for covered services on a case-by-case basis.
If they don't accept the Medicare-approved amount, they can charge up to 15% more than the approved amount. This is called a limiting charge. The limiting charge amount can vary by state. In New York, it's 5%.
Limiting charges may apply to services covered by Part B, but they may not apply to durable medical equipment (DME). Suppliers of DME may charge more than the limiting charge.
When nonparticipating providers submit a claim to Medicare, Medicare pays them 5% less than the amount allowed under the Medicare physician fee schedule. This means nonparticipating providers get paid less than participating providers when they agree to accept assignment.
At the end of each calendar year, physicians can decide whether to change their Medicare participation status or leave it as is.
You can search for healthcare professionals in your area and learn whether they accept assignment using the provider search tool on
Considerations when using a nonparticipating provider
If you anticipate contacting a healthcare professional who is a nonparticipating provider, there are a few things to consider.
Up-front payment
Participating providers typically bill Medicare before asking people to pay a deductible or coinsurance amount. Nonparticipating providers may have you pay the full cost up front. Then, they submit a claim to Medicare on your behalf for any covered services.
If a provider files your claim, you typically receive a Medicare summary notice that includes reimbursement for covered services or equipment. The reimbursement is 80% of the Medicare-approved amount for services covered under Part B.
Limiting charges
You typically pay more when receiving care from a nonparticipating provider, as these providers can charge up to 15% more than the Medicare-approved amount for covered services. Some states have rules governing how large this limiting charge may be.
While a typical Medicare coinsurance is 20% of the Medicare-approved amount, if a person uses a nonparticipating provider with a 15% limiting charge, they are responsible for paying this 15% on top of their 20% coinsurance.
Summary
Medicare nonparticipating providers may choose to accept Medicare assignment on a case-by-case basis. This means they may charge up to 15% more than the Medicare-approved amount for covered services.
The disadvantages of using a nonparticipating provider include paying higher costs for covered services, paying up front for care, and waiting for reimbursement.
The downside for providers is that when they accept assignment, Medicare pays them 5% less than participating providers.
You may wish to factor potential higher costs into the equation when deciding whether to get care from a nonparticipating provider.
