Unraveling Medicare
Navigating the rules, regulations, exceptions, inclusions, and specifications of Medicare can be daunting! Health insurance terminology can feel like a completely different language for most, and Medicare is no exception. When looking for a Medicare plan, you must balance what you need with what you can afford, which can be easier said than done when you’re going it alone.
Why You Need Us
There are various stipulations you need to know, but how can you know if you’re not an expert? Our mission is to help demystify terms like deductibles, copayments, and coinsurance so that you can make the most informed choice for your specific needs.
What is a Deductible in Medicare?
Almost all health plans, including Medicare, have a deductible. This is the money that a member must pay out of pocket before their benefits kick in to pay either the full amount or a percentage, according to the plan coverage. In 2022, the standard deductible for Medicare is $233, and you only need to pay that deductible once per calendar year. Some people opt for a Medigap plan that will pay the Part B deductible. Part B will not pay anything until you meet the $233 out of pocket.
Part A of Medicare works differently and follows the “benefit period,” which covers all services included in Part A coverage. The Benefit Period begins when you are hospitalized and ends 60 days after you’ve gone without any nursing, hospital, or skilled-care services.
Part A benefits, therefore, are not tied to a calendar year, so you can have multiple benefit periods annually, and there is no limit to those periods. In 2022, Medicare requires that you pay $1556 out of pocket related to each “benefit period.”
A Real-Life Example
If you go to the hospital and are admitted on March 9th and then released on March 14th, the benefit period begins on March 9th and will end on May 14th if you seek no services related to the reason that brought you to the hospital post-release date. For that entire coverage period, you would pay a Part A deductible of $1556 once.
If, however, you went home and needed to return on March 23rd, and were released again on March 31st, your benefit period would end on May 31st if you had no other services after the second release date.
Part D Prescription Drug Plans and some Medicare Advantage Plans have annual deductibles, which are the amounts you must pay out of pocket before the plan starts covering expenses.
What is Coinsurance in Medicare?
Coinsurance differs from deductibles because it is the healthcare expense that is covered once you meet your deductible and is typically a percentage of the total cost. For example, once you meet your deductible of $223, your plan might cover 80% of the expense, while you pay the remaining 20%.
For Part A, there is a fixed amount you are covered for inpatient care. For the first sixty days, you are required to pay nothing during the initial benefit period. After that, you are required to pay $389 for all days from day 61 to 90, and $778 from day 91 until you have used up all of your “reserve days,” which are allocated on a lifetime basis and are 60 days. Once those are used up, you have to pay 100% of inpatient care costs. That is when Medigap coverage really pays off – it allows for 365 days, or a full year’s worth, of hospital care coverage once Medicare stops paying.
What is a Copayment in Medicare?
A copayment in Medicare is a dollar amount that does not change what you pay out of pocket for a healthcare service, regardless of what the actual bill is. There are instances where you might be required to pay a copayment and a coinsurance payment, depending on where you are and what your benefit plan states. Copayments sometimes count towards your annual deductible and sometimes do not, but they always count toward your out-of-pocket maximum.
Almost all Medicare Advantage managed care plans have a copayment method, and the amount varies from $10 to $20 (or $50 if you need to be seen in the emergency room). Plans set their own copayments, and the requirements are listed in the Summary of Benefits. Part D is a prescription plan that often uses the copayment system. Some use a “tiered schedule,” which tends to be generic or cheaper alternative drugs with lower copayments, with higher costs for more expensive medications.
What is a Maximum Out-of-Pocket Limit?
When your plan talks about a “maximum out-of-pocket” limit, it is the amount beyond which your plan will pay 100% of all healthcare costs. Typically, your coinsurance and your copayments both go toward the maximum specified by your plan. Your monthly premiums, however, do not count.
Under the original Parts A & B of Medicare, there is no such thing as an out-of-pocket maximum, meaning that you are responsible for all payments of coinsurance, regardless of how much you spend. That is why, in many cases, Medicare itself is not enough to cover you. If you want to ensure that there is a cap for a catastrophe, then additional coverage might be necessary.
Medigap coverage will likely lessen your out-of-pocket maximum. These are plans designed to limit your risks and to pay for all of your coinsurance and deductible requirements under Parts A & B.
Insurance carriers that offer Medicare Advantage must include a maximum that you pay out of pocket per member. Although it can vary, the federal government mandates the maximum yearly amount, which was $7,550 in 2022. Therefore, no plan is allowed to make it higher than that set limit. Most Medicare Advantage plans do not count out-of-network providers in their maximum out-of-pocket, so it is always best to choose an in-network provider.
Part D Is Not Included
When it comes to out-of-pocket maximums, there is no limit for Part D. Regardless of whether you reach your max under Parts A & B, you will still be required to pay Part D copayments. They typically have their own maximum out of pocket or “catastrophic coverage.” In 2022, members are required to pay $7,050 for medication costs before any catastrophic coverage kicks in. Once you hit that limit, the costs for generic medications are $3.70 and $9.20 for brand-name per prescription or a total of 5% of the cost of the drug, whichever is greater.
Main Points Medicare
- The Medicare deductible in 2022 is $233, and you only have to pay this once per calendar year.
- Coinsurance is the percentage you pay after reaching the deductible, usually 20%.
- A copayment is a fixed amount you pay for a healthcare service, regardless of the bill amount.
- The maximum out-of-pocket limit for Medicare Advantage plans is $7,550 in 2022.
- Part D of Medicare has no maximum out-of-pocket limit but has catastrophic coverage after reaching $7,050 in 2022.
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