All Medicare parts have out-of-pocket costs, which may include copayments. Other out-of-pocket costs may also apply, but some people will be eligible for help with covering these expenses.
People enrolled in Medicare will have some out-of-pocket costs for treatments and services.
For example, Medicare Part A has a copayment for inpatient care after a person has been in a hospital for a certain amount of time.
Other copayments may apply to prescription drugs, while Medicare plans that private medical insurers administer may have differing rules on out-of-pocket expenses, including copayments.
This article discusses which Medicare parts have copayments, the other out-of-pocket costs associated with Medicare, and the financial help available.
Medicare parts and plans have out-of-pocket costs that a person must pay toward eligible healthcare treatments, services, and items.
Deductible
A deductible is a set amount that a person must pay before their plan starts to cover expenses. A person must pay the plan deductible in full before coinsurance and copayments apply to eligible costs.
Medicare Part A and Part B have deductibles. Other Medicare plan options may also have a deductible, but these can vary depending on the plan provider.
Copayment
A copayment, which people sometimes refer to as a copay, is a specific dollar amount that a person must pay directly to a healthcare provider at the time of receiving a service.
Coinsurance
A coinsurance is a percentage amount that a person must pay toward their healthcare costs. Part A does not have coinsurance, but Part B does.
Original Medicare comprises parts A and B, but only Part A has a copayment.
People enrolled in Medicare Advantage or Medicare Part D prescription drug plans may pay copayments, but the amount will depend on the plan provider’s rules.
Each private insurer can determine the amount of copayment they will charge.
Medicare Advantage policies have an out-of-pocket maximum, which means that once a person has paid a certain amount in deductibles, copayments, and coinsurance, their plan will cover all future eligible expenses.
The maximum out-of-pocket limit in 2021 is $7,550. After a person has paid this much in deductibles, copayments, and coinsurance, the plan pays 100% of the costs.
Original Medicare has no out-of-pocket maximum.
Medicare Part A provides coverage for care at inpatient hospitals, skilled nursing facilities, and hospices. It also helps with some home healthcare services.
In 2021, Part A has the following costs:
- Premium: Most people will not pay a premium for Part A. For those who do, this ranges from $259 to $471.
- Deductible: A person pays $1,484 for every benefit period. A benefit period begins on the day someone is admitted to a hospital and ends when they have not received any hospital care for 60 days or more in a row.
- Copayment: These change in relation to how long a person stays in the hospital. There is a $0 copayment for days 1 through 60 of a hospital stay. For days 61 through 90, the copayment is $371 per day. For days 91 onward, the copayment is $742 per day.
Medicare Part B helps pay for outpatient costs associated with diagnosing and treating a health condition.
It also pays for some preventive services, including cancer screenings.
Although Part B has no copayment, a person may pay the following costs in 2021:
- Premium: Everyone pays a premium for Part B. The standard premium is $148.50 per month, but this amount could be higher depending on a person’s income.
- Deductible: The 2021 deductible is $203 per year.
- Coinsurance: After a person has paid their deductible, they will be responsible for paying 20% toward eligible healthcare charges. Medicare pays the remaining 80%.
Part D prescription drug plans (PDPs) cover take-home prescription medications.
A person can expect to pay a copayment of no more than $3.70 for generic drugs and $9.20 for brand name drugs in 2021, once they enter the catastrophic coverage stage of their plan.
Also, in 2021, a private insurance company may not charge more than $445 per year for the Part D deductible.
Medicare usually reviews all charges yearly, meaning that the costs for premiums, deductibles, and copayments may change every year.
Private companies may also change the amounts of their out-of-pocket expenses each year, but Medicare usually limits these expenses.
A person can contact their plan provider to ask about the history of copayment charges. They may also find out whether the company plans to raise the out-of-pocket costs in the future.
A person may be eligible for help paying their healthcare costs, and there are several options available.
Medicare supplement insurance
Private insurance companies administer these plans, which are also known as Medigap plans. They help cover gaps in a person’s original Medicare coverage, including premiums and coinsurance.
Medicaid
This federal and state program helps individuals with limited income and resources with healthcare costs.
The program and its eligibility can vary from state to state.
Medicare savings programs
Four state programs help people with limited income and resources pay healthcare costs.
The programs are:
- Qualified Medicare Beneficiary (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Qualifying Individual (QI)
- Qualified Disabled and Working Individuals (QDWI)
Extra Help
The Extra Help program helps people with limited income and resources pay for their prescription medication costs.
Supplemental Security Income (SSI) benefits:
SSI is a cash benefit that the Social Security Administration (SSA) pay. It is different than Social Security retirement benefits.
People eligible for SSI automatically receive Extra Help and may also qualify for Medicaid.
Medicare parts A, C, and D have copayments and may also have deductibles and coinsurance. Medicare Part B does not usually have a copayment.
A copayment is a fixed cost that a person pays toward eligible healthcare claims once they have paid their deductible in full.
If a person is eligible, they may receive help paying their out-of-pocket costs, and benefits are available through state or federal programs to help with medical expenses.