It’s important to know what Medicare copays, coinsurance, and deductibles are in order to find out what you’ll be paying for, and to make the right decision about which Medicare coverage is right for you. Copays, coinsurance, and deductibles are all part of Medicare cost-sharing, or out-of-pocket costs. If these Medicare terms have got you confused, here’s a primer, plus the numbers for 2019.
A deductible is the money you will pay before your benefits kick in. For 2019, the Medicare Part B deductible is $185. This is an amount you pay once per year. Some Medigap plans will cover the Part B (medical insurance) deductible, but if they don’t, you will have to pay this amount.
For Part A (hospital insurance), the deductible is $1,364 per benefit period. A benefit period in Part A begins on the first day you are admitted to the hospital and ends after you have spent 60 days in a row out of the hospital.
A copay is a predetermined amount you pay for health care services at the time you receive care, for example when you visit the doctor, purchase your medication, or visit the hospital. Usually you will not have to pay both a copay and coinsurance on a single service.
Coinsurance is the percentage of your medical bill that you pay. For example, under Medicare Part B, after you meet your deductible you will pay 20% of each medical bill, and Medicare will pay 80%.
For Part A, coinsurance is a set dollar amount that you pay for covered days spent in the hospital. Here are the Part A coinsurance amounts:
- Days 1-60 – $0
- Days 61-90 – $341 per day
- Day 91 on – $682 per day until you have used up your lifetime reserve days (you get 60 lifetime reserve days over the course of your life); after that you pay the full cost
- Skilled nursing facility coinsurance – $170.50
Medigap plans can help you cover 365 additional hospital days.
Maximum Out-of-Pocket Limit
The maximum out-of-pocket limit is the dollar amount beyond which your plan will pay for 100% of healthcare costs. Copayments and coinsurance go toward this limit, but monthly premiums don’t. Here are the details on maximum out-of-pocket limits:
- Original Medicare – no out-of-pocket limit.
- Medigap plans – help to pay Part A and B deductibles and coinsurance so that your out-of-pocket costs don’t get too high.
- Medicare Advantage plans – most have an out-of-pocket maximum of $6,700 (may differ by plan but can’t be higher than $6,700).
For Part D, copay and coinsurance are separate from your Medicare plan. If your part D plan has a deductible, you pay that first. After that, copay or coinsurance are what you pay for each prescription. Part D plans have different tiers as part of the Part D formulary, in which different types of drugs incur lower or higher copays. These will differ according to your individual Part D plan.
- Copayments in Part D are when you pay a set cost (for example, $10) for all drugs in a certain tier. Generic drugs usually have a lower copayment than brand-name drugs.
- Coinsurance in Part D means that you pay a percentage of the cost of the drug (for example, 25%).
- Catastrophic coverage in Part D for 2019 – $5,100. Once you have paid $5,100 in medications, your costs for medications will be $3.40 per generic drug, and $8.50 or 5% (whichever is greater) per brand-name drug.
Make sure, if you have a plan (Medicare Advantage, Part D) that charges more for out-of-network providers, that you stay in your network of doctors if you need to save money. Read your benefits summary carefully to see how your plan handles copays, coinsurance, and deductibles so you won’t be in for any surprises. Under some Medicare Advantage plans, out-of-network expenses do not count toward the maximum out-of-pocket limit, so beware of costs that can add up.