Like most insurance, Medicare beneficiaries have a variety of out-of pocket costs. One of these is the Medicare deductible. Every benefit period, you must meet the deductible before Medicare begins paying its share of covered costs.
The Medicare Part “A” deductible is for each initial benefit period for the 1st 60 days . The benefit period begins as soon as you are admitted to the hospital or skilled nursing facility as an inpatient. It ends when you go 60 days without receiving covered care as an inpatient. Re-admittance to the hospital at any point during that 60-day period – including on day 60 – is considered part of the same benefit period.
You owe the Part A deductible for each benefit period. You may have multiple Part A benefit periods during a calendar year.
The Medicare Part “B” benefit period is one calendar year. You must pay the Part B deductible every year. The Medicare Part B deductible usually changes each year and once you pay this amount, Medicare begins paying its share of costs for covered services.
If you have a Medicare Advantage Plan (MA) or Part D plan, you may have additional deductibles. Details for these are determined by the private insurance company that provides your plan. Contact your provider to learn more about the deductible and benefit period under your MA only plan.
Under Original Medicare, your share of covered expenses is called co insurance.
Medicare Part A co-insurance varies according to the number of days you spend as an inpatient. Each benefit period begins a new co-insurance calculation.
• Days 1-60: you pay an initial deductible per hospital stay • Days 61-90: co-insurance expense per day
• Days 91 through 150 lifetime reserve days: co-insurance per day
You get a total of 60 lifetime reserve days throughout the time you have Medicare. If you use all 60 of your lifetime reserve days, you pay 100 percent of inpatient care costs thereafter. However, if you have a Medigap plan, you get an addition 365 lifetime reserve days.
Most Medicare Part B services have a Medicare-approved cost. Assuming you receive care from a provider who accepts assignment, Medicare typically pays 80 percent of this amount. The remaining 20 percent is your coinsurance amount.
Medicare Advantage and Part D beneficiaries typically pay a fixed dollar amount for services, otherwise known as co-pays. Some plans charge both co-pays and co-insurance, but these are rare. Common co-pays for a Medicare Advantage plan maybe $15 for primary care visits and $30 to see a specialist within your network.
Most Part D plans have tiered pricing as a means to control costs. Co-pays rise along with the tiers. For example, your co-pay for prescriptions on the lowest tier may be only $1 to $3. Co-pays on the next tier may range from $5 to $12, then $15 to $30, and so on.
Medicare Part D and Medicare Advantage plans all have maximum out-of-pocket limits. This means that, once you meet this threshold, you have no further out-of-pocket costs for the rest of the year. There is no out-of-pocket maximum for Original Medicare. If you have multiple or lengthy hospital stays, your costs could be substantial.
There is no out-of-pocket maximum for Original Medicare. If you have multiple or lengthy hospital stays, your costs could be substantial.