Summary: Medicare copays and coinsurance are out-of-pocket costs you’ll be responsible for paying when receiving Medicare-covered services. How much you pay will vary depending on your coverage and the service you are receiving. Below, we’ll cover copayments and coinsurance across all parts of Medicare. Estimated Read Time: 7 min
Understanding Copayments and Coinsurance for Medicare
Medicare copayments and coinsurance are out-of-pocket costs you pay for certain Medicare-covered services. You may be responsible for Medicare copays or coinsurance after Original Medicare pays their portion of your medical bill. With Original Medicare, there is no annual limit on how much you can spend on copays or coinsurance. The only way to combat this is to enroll in a Medicare Supplement plan or a Medicare Advantage plan.
Depending on your healthcare needs, these out-of-pocket costs can add up quickly, especially without supplemental coverage to help cover a portion of your bill. Understanding how Medicare copayments and coinsurance work will help you better budget your healthcare costs.
What are Copayments for Medicare?
Medicare copayments are a set amount that you pay for a Medicare-covered service. For example, if you use Medicare Part A benefits, you are responsible for a copay each day you’re in the hospital . This copay amount can range from $0 to $800 depending on the length of your stay. Medicare copays vary between services but will always be a predetermined dollar amount.
What is Medicare Coinsurance?
Medicare coinsurance is a percentage of the total cost that you are responsible for when you receive Medicare-covered services. For example, you typically pay a 20% coinsurance for each Medicare Part B covered service you receive. If you receive a service that costs $100, Medicare will pay 80%, and you will be responsible for the remaining 20%, which would be $20.
Since Medicare coinsurance is a percentage, what you pay will vary depending on the cost of your service or item. Remember, Original Medicare has no out-of-pocket maximum limit. Thus, you are responsible for paying 20% of your Part B bill regardless of how high the bill may be or how much you have paid throughout the year.
Medicare Part A Copays
When using your Medicare Part A coverage, you will generally deal with set copayments for inpatient services in addition to your Medicare Part A deductible. When using Medicare Part A benefits, you will be responsible for paying a daily copayment once you’ve stayed over a certain number of days depending on the type of facility you are receiving care in. Medicare Part A copayments begin on your 61st day for hospital inpatient care and on your 21st day for a skilled nursing facility.
Inpatient Hospital Stay
- Days 1-60: $0 after deductible
- Days 61-90: $400 copayment for each day
- Days 91-150: $800 copayment for each day (while using your 60 lifetime reserve days)
- After day 150: You pay all costs
Skilled Nursing Facility
- Days 1-20: $0 copayment
- Days 21-100: $200 copayment each day
- After day 101: You pay all costs
- $0 for covered hospice care services
- Up to $5 for each prescription drug for pain relief and symptom control while at home
If your inpatient stay reaches 91 days, you will begin using your lifetime reserve days. Lifetime reserve days are set aside to help cover the costs for extended hospital stays past what Medicare Part A would typically cover. Each Medicare beneficiary enrolled in Part A is given 60 reserve days that can be used when you’re in the hospital past the 90-day mark.
During this time, you will be responsible for paying an $800 daily copayment, and once you run out of lifetime reserve days, you will be responsible for paying all costs. Remember, copayments reset each benefit period. However, once you run out of lifetime reserve days, you will not be able to use them again.
Medicare Part B Coinsurance
Medicare Part B coinsurance is 20% of the cost for each Medicare-covered out-patient service or item you receive. After meeting your annual deductible, you are responsible for paying your Medicare Part B coinsurance each time you receive outpatient care.
You will be responsible for paying the Medicare Part B coinsurance for services such as:
- General healthcare services (such as a doctor’s visit)
- Durable medical equipment, including wheelchairs, walkers, etc.
- Outpatient mental health care (visiting a doctor to diagnose or treat a condition)
- Outpatient hospital care
Keep in mind, you could pay excess charges for your Medicare Part B services if your provider does not accept Medicare assignment. This is an additional 15% on top of the approved amount for a service. Meaning you could incur an additional cost if your provider charges more than Medicare will allow.
When a healthcare provider accepts Medicare assignment, they accept the Medicare-approved amount as the full payment. If they do not accept Medicare Assignment, they must display a notice to communicate the potential additional costs you could be subject to.
Medicare Part C Copays and Coinsurance
Medicare Part C copayments and coinsurance vary by plan and carrier. When comparing Medicare Advantage (Part C) plans, you’ll want to consider copayments and coinsurance for covered services on each plan in your area.
For example, instead of paying the 20% Medicare Part B coinsurance for a doctor’s visit, your Part C plan may have you pay a fixed copay . Depending on your plan, your out-of-pocket costs could be greater than or less than what you would pay with Original Medicare, so it is always essential to research and compare plans.
Unlike Original Medicare, every Medicare Advantage plan has an annual maximum out-of-pocket (MOOP). Thus, you will not be responsible for any Medicare-covered costs after reaching your maximum out-of-pocket limit for the year. Any time you pay a copayment or coinsurance, the costs contribute to your MOOP.
Medicare Part D Copays and Coinsurance
Medicare Part D copayments and coinsurance are the amount you pay out-of-pocket for prescription drugs. Your costs, including deductibles, copays, and coinsurance, contribute to spending limits which determine each Medicare Part D coverage phase. Moving through Part D coverage phases will change the amount you pay out-of-pocket, so it is essential to understand your copay or coinsurance for each coverage phase.
During the initial coverage phase, you will pay copays for your prescriptions. Copayment amounts are determined by which tier your medication is in on your plan’s formulary. Generally, the higher the tier, the higher your copay will be. Once you reach the coverage gap, also known as the donut hole, you will pay 25% coinsurance for brand-name and generic drugs. However, this coverage gap will be eliminated on all Medicare Part D plans in 2025.
Once through the coverage gap, upon reaching the catastrophic coverage phase, you will only be responsible for paying a small coinsurance of 5% for your medications. You will be in this phase for the rest of the year and your coinsurance will stay the same.
How to Get Help With Your Medicare Copayments & Coinsurance
For some, Medicare copays and coinsurance costs can add up quickly. A few options are available to help with paying your Medicare copayments and coinsurance.
Medicare Supplement (Medigap) plans can help cover your Medicare Part A and Part B coinsurance and copayments. Plans may offer coverage for the following:
- Medicare Part A coinsurance hospital costs (up to 365 days after Medicare benefits are used up)
- Medicare Part A hospice care coinsurance and copays
- Skilled nursing facility coinsurance
- Medicare Part B coinsurance
- Medicare Part B preventative care coinsurance
There are multiple Medicare Supplement plans available which provide different coverage; however, not all plans are available in all areas. You can see which plans are available in your area and what coverage they offer by visiting our online rates form.
Dual-eligible individuals who qualify for Medicare and Medicaid can also receive help paying their Medicare Part C or Part D copayments and coinsurance. Special Needs plans and Extra Help assist with out-of-pocket costs to Medicaid and low-income recipients.
Learn More About Medicare Copays and Coinsurance
Understanding your Medicare out-of-pocket costs can significantly impact your monthly and annual budgeting. If you need help figuring out what your coverage will cost or are looking for options to reduce your out-of-pocket spending, give us a call.
Medicare Costs, Medicare.gov. Accessed August 2023
Mental Health Care (Inpatient), Medicare.gov. Accessed August 2023
Copayment/Coinsurance in Drug Plans, Medicare.gov. Accessed August 2023