Participating vs non-participating Copy link
A participating provider accepts the full fee schedule amount as payment in full. After the Part B deductible, Medicare pays 80% and the patient owes 20% coinsurance, and the patient can never be billed beyond that. A non-participating provider is paid on a schedule reduced by 5% (the non-participating amount is 95% of the full amount), but may choose claim by claim whether to accept assignment. Only on an unassigned claim does the limiting charge come into play: it caps what the patient can be billed directly.
The math Copy link
Limiting charge = 115% × the non-participating amount = 115% × 95% of the fee schedule amount—that is, 109.25% of the regular Medicare rate. Because the calculation starts from the fee schedule amount for the setting where the service is delivered, there is a non-facility limiting charge (109.25% of the office amount) and a facility limiting charge (109.25% of the facility amount)—see facility vs non-facility for why those two amounts differ. Every payable code page shows its limiting charge in the common questions—for example, CPT 99213.
Where it applies—and where it doesn't Copy link
The limiting charge applies only to unassigned claims from non-participating providers for Physician Fee Schedule services. It never applies to participating providers, to assigned claims, or to providers who have opted out of Medicare entirely (they bill under private contracts instead, outside the fee schedule). Some states restrict balance billing further than federal law does, so the federal limiting charge is a ceiling, not a guarantee that the full 109.25% may be billed everywhere.
Limiting charge calculator Copy link
Enter the participating fee schedule amount for the code, locality and setting. For CPT 99213 in an office in Chicago, IL (Q4 2026), the participating amount is $99.63, the non-participating amount is $94.65 (95%), and the limiting charge on an unassigned claim is $108.85 (115% of the non-participating amount).
- Non-participating amount (95%)
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- Limiting charge (115% of non-par)
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- Limiting charge as % of par
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Applies only to unassigned claims from non-participating providers. State law can restrict balance billing further.
Frequently asked Copy link
How do I calculate the limiting charge from the Medicare rate?
Multiply the fee schedule amount by 1.0925—the 5% non-participating reduction (×0.95) followed by the 115% cap (×1.15). For example, a $100.00 Medicare amount gives a $95.00 non-participating amount and a $109.25 limiting charge.
What is the non-facility limiting charge?
The limiting charge computed from the non-facility (office) fee schedule amount: 109.25% of the office rate. The facility limiting charge is the same calculation applied to the facility amount.
Does the limiting charge apply if my provider accepts assignment?
No. On an assigned claim the provider accepts the Medicare-approved amount as payment in full, and the patient owes only the deductible and 20% coinsurance. The limiting charge only matters on unassigned claims from non-participating providers.
Sources Copy link
Written from primary CMS sources—see how we source, compute, and verify everything on this site.
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