The My Medicare Matters Team
Enrolling in a Medicare plan is a big decision. While you’re able to switch plans each year if you’re unhappy (in some situations more frequently) you still want to choose the best plan for your needs the first time. This means taking your out-of-pocket costs into consideration along with other factors. Medicare covers a wide range of medical services, but most are not free. Here’s what you should expect to pay out-of-pocket throughout the year if you’re enrolled in a Medicare Advantage/Part C plan.
Premiums are the amount you pay each month out-of-pocket for your Medicare Advantage (MA) plan. The estimated average monthly MA plan premium for 2019 is $28, this cost may vary significantly. Some could be $0, while others could have premiums over $200.
To join an MA plan, you must also be enrolled in Medicare Parts A & B. It’s important to remember that Part B has a separate premium that you are responsible for paying even if you enroll in a Medicare Advantage/Part C plan. The standard Part B premiums in 2019 is $135.50. per month. You may pay more if you delayed enrolling into Medicare Part B and have a penalty, have higher income, and/or have under 40 Social Security work credits.
A deductible is the amount paid out of pocket by a beneficiary or insured individual before benefits begin. Only some Medicare Advantage plans have an annual medical deductible. However, many Medicare Advantage plans that include Part D/prescription drug coverage may charge another deductible for drug coverage.
Copayment/Coinsurance are the portion of cost you pay for covered drugs or service like doctors’ visits, also referred to as cost-sharing. The amount varies, but copays are usually a flat fee while coinsurance is not a fixed dollar amount. Instead, it is a percentage of the cost of the item/service that the patient must pay. For example, a 25% coinsurance means that the patient is responsible for 25% of cost while the plan covers 75% of the cost. Keep in mind that plans often charge higher copay and co-insurance amounts for out-of-network providers.
Maximum Out-of-Pocket Costs
These out-of-pocket costs (premiums, deductibles, and copayment) vary in each MA plan and can change every year, but the maximum out-of-pocket spending limit is consistent for all plans. For 2019 the max you will spend is $6,700, this amount changes every year. The out-of-pocket maximum for plans that allow you to see out of network providers may be higher. If your Medicare Advantage plan includes prescription drug coverage you will have a separate out-of-pocket maximum for prescription drug costs.
- If you’re enrolled in an HMO, you’ll need a referral from your primary care physician to visit a specialist and there is a separate copay for that appointment.
- If you’re enrolled in an HMO, be sure that any specialist you see refers you to an in-network lab or testing facility.
- If you’re enrolled in a Special Needs Plan (SNP) designed for individuals enrolled in both Medicare and Medicaid, most of your costs are typically covered by Medicare and Medicaid.
There are lots of considerations when choosing a Medicare plan, which is why it’s important to look at the 4 Cs when making a decision. Don’t hesitate to speak with a Medicare expert about your options.