Medicare includes out-of-pocket expenses that you must pay. Copays are a predetermined amount of money you will be required to pay for a specific medical service or prescription.
- Medicare is a government-funded health insurance option for Americans age 65 and older and individuals with certain qualifying disabilities or health conditions.
- Medicare beneficiaries are responsible for out-of-pocket costs such as copayments, or copays for certain services and prescription drugs.
- There are financial assistance programs available for Medicare enrollees that can help pay for your copays, among other costs.
Medicare is one of the most popular health insurance options for adults age 65 and older in the United States. When you enroll in Medicare, you will owe various out-of-pocket costs for the services you receive.
A copayment, or copay, is a fixed amount of money that you pay out-of-pocket for a specific service. Copays generally apply to doctor visits, specialist visits, and prescription drug refills. Most copayment amounts are in the $10 to $45+ range, but the cost depends entirely on your plan.
Certain parts of Medicare, such as Part C and Part D, charge copays for covered services and medications. Deductibles, copays, and coinsurance fees all contribute to the out-of-pocket maximums for these plans.
In this article, we’ll explore the parts of Medicare that charge copay fees, how to compare copay costs when enrolling in a Medicare plan, and how to find help paying your out-of-pocket costs.
Medicare functions somewhat differently than traditional private insurance when it comes to cost-sharing in that it does not charge copays for original Medicare services. Here’s a quick glance at what the basic copay structure is for Medicare:
- If you’re enrolled in original Medicare, you won’t owe a copay for the services you receive under Part A and Part B — instead, you will owe a coinsurance amount.
- If you are enrolled in Medicare Advantage (Part C), your plan can charge you a copay for doctor and specialist visits, as well as prescription drugs if they are covered.
- If you are enrolled in Medicare Part D for prescription drug coverage, your plan can charge a copay for prescription drugs — this amount differs depending on the tier your drugs are in within the plan’s formulary.
Let’s look at some of the copays you may come across when you are enrolled in the various parts of Medicare.
- monthly premium, which varies from $0 up to $471
- per benefits period deductible, which is $1,484
- coinsurance for inpatient visits, which starts at $0 and increases with the length of the stay
These are the only costs associated with Medicare Part A, meaning that you will not owe a copay for Part A services.
- monthly premium, which is $148.50 or higher
- yearly deductible, which is $203
- coinsurance for services, which is 20 percent of the Medicare-approved amount for your services
Like Part A, these are the only costs associated with Medicare Part B, meaning that you will not owe a copay for Part B services.
Part C (Medicare Advantage)
You may see the following costs for your Part C services, depending on your plan:
- all costs associated with Part A
- all costs associated with Part B
- monthly plan premium
- yearly plan deductible
- prescription drug plan deductible
- primary doctor visit copay
- specialist visit copay
- prescription drug copay
The Part C costs listed above will vary depending on the plan — and type of plan — you are enrolled in. Most Medicare Advantage plans are either Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) plans, which means that you will even owe different amounts depending on if the services are in network or out of network.
Under Medicare Part D, you are covered for prescription drug medications you may require. You’ll pay the following costs for your Part D prescription drug plan:
Part D plans use a formulary structure with different tiers for the medications they cover. The copay or coinsurance amount for your medication depends entirely on what tier it is in within your plan’s formulary. Your drug costs may also vary depending on whether you are in the donut hole of your prescription drug plan or not.
Medicare supplement (Medigap)
Under Medigap, you are covered for certain costs associated with your Medicare plan, such as deductibles, copayments, and coinsurance amounts. Medigap plans only charge a monthly premium to be enrolled, so you will not owe a copay for Medigap coverage.
While there are no copays associated with original Medicare, you may owe variable coinsurance amounts for the services you receive. These coinsurance amounts generally take the place of copays you might otherwise owe for services under original Medicare and include:
- $0 to $742+ daily coinsurance for Part A, depending on the length of your hospital stay
- 20 percent coinsurance of the Medicare-approved amount for services for Part B
Since Medicare Part C and Part D plans are sold by private insurance companies, they can choose what copayment amounts to charge for their covered services. Part C and Part D copay amounts vary depending on the plan you enroll in, and are usually determined by the benefits you receive, the plan type you choose, and the location in which you live.
Medicare is available for certain individuals who meet eligibility requirements. These requirements include:
- individuals age 65 and older
- individuals who have been receiving disability benefits for a period of at least 24 months
- individuals who have been diagnosed with amyotrophic lateral sclerosis (ALS) or end stage renal disease (ESRD)
Most individuals will need to enroll into Medicare on their own, but people with qualifying disabilities will be automatically enrolled after 24 months of disability payments.
You can enroll in original Medicare directly through the Social Security’s website during your initial enrollment period. This period includes the 3 months before, the month of, and the 3 months after your 65th birthday.
If you miss your initial enrollment period or want to change or enroll in a different Medicare plan, here are the additional enrollment periods:
- General and Medicare Advantage enrollment: from January 1 to March 31
- Open enrollment: from October 15 to December 7
- Special enrollment: a number of months depending on your circumstances
The initial enrollment period is the time in which you can enroll into Medicare parts A and B. Once you’re enrolled in original Medicare, though, you may decide that you would rather enroll into a Medicare Advantage plan.
Before you choose an Advantage plan, you’ll want to shop around to compare the different plans available in your area. Comparing benefits, health perks, and plan costs — including copay amounts — can help you choose the best Medicare Advantage plan for you.
Help paying for Medicare
If you’re having trouble meeting your Medicare copays or other costs, you may qualify for financial assistance through a variety of federal- and state-funded programs.
- Medicare Savings Programs (MSPs). Medicare offers four savings programs to help pay some of the costs associated with Medicare. Most of the programs are aimed at helping pay Medicare premiums however, the Qualified Medicare Beneficiary (QMB) program can help cover copays, as well.
- Extra Help. Medicare Extra Help is a program that offers financial assistance to Medicare beneficiaries for Medicare Part D costs. It can help cover prescription drug coinsurance and copays when refilling your medications.
- State Health Insurance Assistance Programs (SHIPs). SHIPs are state-run assistance programs that can help Medicare enrollees who have questions or concerns about their plan. This may include finding financial assistance that is available to help you pay Medicare costs, such as premiums, deductibles, copays, and more.
- Medicaid. Medicaid is a federally funded health insurance option for low-income individuals in the United States. Medicare beneficiaries who also qualify for Medicaid can use Medicaid to help cover some of the costs associated with Medicare-covered services, including copays.
- You will find you are responsible for certain copays when you enroll in certain parts of Medicare, such as Medicare Part C and Medicare Part D.
- Medicare Part C plans generally charge copays for doctors’ and specialists’ visits, as well as prescription drug refills. Medicare Part D plans charge either a copay or coinsurance for medication refills, but not both.
- If you need financial assistance for copays or other fees associated with your Medicare plan, there are programs available that can help you cover these out-of-pocket costs.