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With today’s rising costs, keeping an eye on how much you pay for healthcare is essential for your financial wellbeing – especially if you are living on a fixed budget. That's why it's important to know what you might have to pay out of pocket for healthcare before any major (or minor) health issues pop up.

Before we dive into the topic of Original Medicare copays and beyond, let's take a quick look at what copays are, what coinsurance is and how deductibles play a role:

  • Deductible – A deductible is the amount you pay for covered health care services before your insurance plan pays. So, if you have a $2,000 deductible, for example, you have to pay the first $2,000 of covered services yourself. After that, you should ideally pay only a copay or coinsurance.
  • Copay – A copay (short for copayment) is a set rate you pay ($10, for example) for a covered health care service after you've already paid your deductible. For instance, if you go to the doctor and you've met your deductible, your copay in this example should only be $10. (Remember, copays can vary for things like prescription drugs, lab tests and visits to specialists.)
  • Coinsurance – Coinsurance is not a set amount like a copay. Instead, it's a percentage of costs you pay after you've met your deductible. Let's say your health insurance plan allows $100 for an office visit and your coinsurance is 20%. If you've met your deductible, you pay 20% of $100, or $20.

Now, let's look at the different Medicare plans and their copay and coinsurance costs so you can stay in-the-know and avoid sticker shock.

Medicare Part A Copays and Coinsurance

Medicare Part A is also known as hospital insurance. It covers inpatient care at a hospital, as well as inpatient care at places like skilled nursing facilities and nursing homes (that are not custodial or long-term care), as well as hospice care and home health care. After you meet the deductible, which is $1,632 (up from $1,600 in 2023) for each in-patient benefit period, here's what you can expect to pay:

Inpatient Hospital Stay

  • Days 1-60: $0 after you pay your deductible.
  • Days 61-90: $408 copay each day.
  • Days 91-150: $816 copay each day while using your 60 lifetime reserve days.
  • Days 150+: You pay all costs.

Skilled Nursing Facility Stay

  • Days 1-20: $0.
  • Days 21-100: $204 copay each day.
  • Days 101+: You pay all costs.

Home Health Care

  • $0 for covered services.
  • 20% of the approved amount for equipment (like wheelchairs, walkers, hospital beds, etc.).

Hospice Care

  • $0 for covered services.
  • Up to $5 for each prescription drug or other pain relief product.

Medicare Part B Copays and Coinsurance

Medicare Part B is medical insurance. It covers things like doctors' visits, outpatient care, medical supplies and preventive care. It can also cover the health care services or supplies needed to diagnose or treat an illness, injury, condition or disease. After you meet your Plan B deductible of $240, here's what you can expect to pay:

Clinical Lab Services

  • $0 for covered services.

Home Health Care

  • $0 for covered services.
  • 20% of the Medicare-approved amount for equipment (like wheelchairs, walkers, hospital beds, etc.).

Inpatient Hospital Care

  • 20% of the approved amount for most services.

Outpatient Mental Health Care

  • $0 for yearly depression screening.
  • 20% of the approved amount for visits to your doctor or providers to diagnose or treat your condition.

Partial Hospitalization Mental Healthcare

  • 0% of the approved amount for each service you get from a doctor or qualified mental health professional.
  • Coinsurance for each day services you get in a hospital outpatient setting or community mental health center.

Outpatient Hospital Care

  • Usually 20% of the approved amount for services.
  • Copayment to the hospital for each service you get in an outpatient setting (except for certain preventive services).

Medicare Part C Copays and Coinsurance

Medicare Part C, also known as Medicare Advantage, is a plan from a private company approved by Medicare that offers an alternative to Original Medicare coverage. It's generally a bundled plan that includes Part A, Part B, and often Part D (which you can read more about below). Costs vary depending on the company and plan, so it's hard to say exactly what you'll pay. But many people choose these plans to keep out-of-pocket costs lower. You may also get extra coverage for things like vision, hearing and dental, which aren’t usually covered by Plan A or Plan B, with some medical exceptions.

Medicare Part D Copays and Coinsurance

Medicare Part D is an optional plan that helps you pay for outpatient prescription drugs. As with Part C, Medicare contracts out with private companies that offer this insurance coverage. Because of this, plans, coverage and copay prices will vary. As mentioned above, Medicare Advantage plans often include Part D. Without this type of coverage, you may be stuck paying out of pocket for any outpatient prescription drugs. No matter which coverage you choose, it's important to do your homework, know your options and find a plan that works for you. Need help? Learn more about Wellcare Medicare Advantage plans and let us help you find one that fits your needs.

 

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Disclaimers

Sources

Healthcare.gov Glossary
Medicare.gov - Medicare Costs
Medicare.gov - What Medicare Part A Covers

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Y0020_WCM_134133E Last Updated On: 2/4/2024