How Do I Pay for Medicare?

Medically reviewed by Timothy J. Legg, PhD, NHA, NEA-BC, FACHCA on May 25, 2016Written by Tracy Everhart on May 25, 2016

If you’re considering retirement, you can never start planning too early. It’s best to start planning at least three months before you turn 65. This will help you make an informed decision and avoid penalties for missing the enrollment period.

Does everyone qualify for Medicare coverage?

If you’re nearing 65 or you’re already 65 or older, you need to answer a few basic questions:

  • Are you a U.S. citizen or legal resident?
  • Have you have resided in the United States for a minimum of five years?
  • Have you worked at least 10 years in Medicare-covered employment or contributed the equivalent through self-employment taxes?

If you answered yes to all of these questions, you qualify to enroll in Medicare. If you do not meet this criteria, you can still enroll in Medicare but you will have to pay a monthly premium.

For most people, Medicare Part A (hospitalization) will be provided to you at no charge. Medicare Part B (doctor visits/medical care) of the traditional Medicare plan is an elected plan. You’ll pay a premium each month for Medicare Part B. If you get Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your Part B premium will be deducted automatically from your benefit payment. If you don’t get these benefit payments, you’ll get a bill.

If you’re interested in Medicare Advantage Plans (combination coverage) either through initial enrollment or a change in coverage, you have a lot of factors to consider. The key is to look for a plan that meets all of your needs and fits within your budget. You will pay higher monthly premiums in exchange for lower out-of-pocket expenses. In most cases, there will be deductibles and copays for most medical services, products, and procedures. If you elect Medicare Plan D (prescription) coverage, you will also pay a monthly premium.

How much does each plan cost?

Each Medicare plan has different offerings and different costs. Here’s a look at the costs associated with each plan, including premiums, copays, and out-of-pocket expenses.

Medicare Part A - Hospitalization

  • For most people, Part A will be provided to you at no charge.
  • If you need to buy Part A, you’ll pay up to $411 each month.
  • A deductible amount of $1,288 must be paid for by the insurance policy holder (you) for each benefit period.
  • Copayments are based on the number of days of hospitalization.
  • Late enrollment fees can be equal to 10 percent of your premium amount. The fees are payable for twice the number of years you were not enrolled.
  • There is no out-of-pocket maximum for the amount you pay.

Medicare Part B - Medical/doctor visits

  • Most people pay $121.80 each month. Some higher-income people pay more.
  • The deductible is $166 per year. After your deductible is met, you typically pay 20 percent of the cost of the services.
    • $0 for Medicare-approved laboratory services
    • $0 for home healthcare services
    • 20 percent of the Medicare-approved amount for durable medical equipment, such as a walker, wheelchair, or hospital bed
    • 20 percent for outpatient mental health services
    • 20 percent for outpatient hospital services
  • Late enrollment fees can be equal to 10 percent of your premium amount. The fees are payable for twice the number of years you were not enrolled.
  • There is no out-of-pocket maximum for the amount you pay.

Medicare Part C - Advantage Plans (hospital, doctor, and prescription)

  • The Part C monthly premiums vary based on your reported income for two years, the benefit options, and the plan itself.
  • The amount you pay for Part C deductibles, copayments, and coinsurance varies by plan.
  • Like traditional Medicare, Advantage Plans make you pay part of the cost for covered medical services. Your share of the bill typically ranges from 20 percent to 40 percent or more, depending on the care you receive.
  • All Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. The average out-of-pocket limit typically ranges from $3,000 to $4,000. In 2016, the maximum out-of-pocket limit is $6,700.
  • With most plans, once you reach this limit, you’ll pay nothing for covered services.
  • Any monthly premium you pay for Medicare Advantage coverage does not count towards your plan’s out-of-pocket maximum.
  • Any costs paid for outpatient prescription drug coverage (Part D) do not apply to your out-of-pocket maximum.

Medicare Part D - Prescription drugs

  • The Part D monthly premiums vary by the plan you choose and the area of the country you live in. They can range from $10 to $100 per month.
  • Premiums may be higher based on your reported income for two years before enrollment.
  • The amount you pay for your Part D annual deductible can’t be more than $360.
  • Copayments: After you reach a predetermined amount (usually around $3,300), you have reached the coverage gap. During the coverage gap you will have to pay 45 percent for most brand name drugs and 58 percent for generic drugs.
  • Catastrophic Coverage: Once you reach $4,850, you pay 5 percent of the cost of the medication, or $2.95 for generic and $7.40 for name brand (whichever is greater).
  • Late enrollment fees can be equal to 10 percent of your premium amount. The fees are payable for twice the number of years you were not enrolled.

How can you reduce your Medicare costs?

Make sure that you enroll during you required time to avoid possible penalties, and only elect the coverage that you think you will use. If you take few prescription medications or you take low cost drugs, you may not want to purchase prescription drug coverage. Whether you choose a prescription drug plan or not, generic medications can always save you money.

Some programs through Medicare can also help you pay for your premiums. To qualify for the programs, you must:

  • be eligible for Part A
  • have an income level equal to or less than the maximum amounts per program
  • have limited resources

The four programs currently available are:

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualified Individual (QI) Program
  • Qualified Disabled Working Individuals (QDWI) Program

These programs can help you pay for Part A and Part B premiums, and other costs like deductibles, coinsurance, and copayments.

CMS Id: 104430