When you get Medicare, or buy Medicare Supplement Insurance, you need to familiarize yourself with some key terms. After all, you want to know exactly what your coverage includes and which costs you have to pay out of pocket. Specifically, you need to understand the difference between Medicare copayments and coinsurance for Original Medicare and Medigap policies.
What Are Copayments?
In the healthcare world, copayments are set fees you have to pay for some services or medical supplies. The copayment tends to be low, such as $10 or $20, and it only applies to specific things such as a doctor’s office visit.
Does Medicare Part A Cover Copayments?
Medicare Part A, which includes hospital stays, skilled nursing home stays, and hospice care, covers nearly all applicable copayments. That means you’ll rarely have to contribute a copay when you go to the hospital, stay in a nursing home, or receive hospice care.
When you’re in hospice, you might be responsible for a $5 copay for any prescription drugs you receive to manage pain and other symptoms. You might also have to cover a minor copayment for respite care or short-term inpatient care related to a hospice stay.
Does Medicare Part B Cover Copayments?
Medicare Part B, which includes most doctor visits, durable medical equipment, and some home health care, covers most copayments. While you don’t have to contribute a copayment when you visit the doctor’s office, you typically do have to pay one when you get outpatient hospital or mental health services.
Which Medigap Plans Cover Copayments?
There are 10 standardized Medicare Supplement Insurance policies, and many cover all or part of Medicare-related copayments. These costs are included in the following Medigap plans:
- Part A hospice care copayment and Part B copayment: Plan A, Plan B, Plan C, Plan D, Plan F, Plan G, Plan M, and Plan N
- 50 percent of Part A hospice care copayment and 50 percent of Part B copayment: Plan K
- 75 percent of Part A hospice care copayment and 75 percent of Part B copayment: Plan L
What Is Medicare Coinsurance?
Medicare covers most of your medical costs, but it doesn’t include everything. Coinsurance is the share you have to pay after reaching your deductible. Unlike a copayment, coinsurance is usually a percentage of the total cost.
Does Medicare Part A Cover Coinsurance?
According to Medicare.gov, Medicare Part A covers some coinsurance for hospital, mental health, and skilled nursing facility stays. For hospital and mental health inpatient stays, you pay no coinsurance for the first 60 days, $329 coinsurance per day for Days 61 through 90, and $658 coinsurance per day for Days 91 and beyond. For skilled nursing facility stays, you pay no coinsurance for the first 20 days and $164.50 coinsurance per day for Days 21 through 100. Keep in mind that these coinsurance costs apply to services received in 2017, and Medicare costs are adjusted each year.
Does Medicare Part B Cover Coinsurance?
Medicare Part B coinsurance is more straightforward because the same amount typically applies to all services. After you meet your deductible, which is $183 per year in 2017, you’ll pay 20 percent coinsurance for most doctor visits, outpatient services, and durable medical equipment. Part B coinsurance doesn’t apply to some preventive services, so be sure to ask your doctor for confirmation.
Which Medigap Plans Cover Coinsurance?
Several Medicare Supplement Insurance policies alleviate your out-of-pocket costs by covering coinsurance. The following plans include coinsurance costs:
- Part A coinsurance and hospital costs up to 365 days after you’ve used up your Medicare benefits, Part A hospice care coinsurance, and Part B coinsurance: Plan A and Plan B
- Part A coinsurance and hospital costs up to 365 days after you’ve used up your Medicare benefits, Part A hospice care coinsurance, Part B coinsurance, and skilled nursing facility care coinsurance: Plan C, Plan D, Plan F, Plan G, Plan M, Plan N
- Part A coinsurance and hospital costs up to 365 days after you’ve used up your Medicare benefits, 50 percent of Part A hospice care coinsurance, 50 percent of Part B coinsurance, and skilled nursing facility care coinsurance: Plan K
- Part A coinsurance and hospital costs up to 365 days after you’ve used up your Medicare benefits, 75 percent of Part A hospice care coinsurance, 75 percent of Part B co-insurance, and skilled nursing facility care coinsurance: Plan L
More FAQs about Medicare Copayments and Coinsurance
Can I use a Medigap policy with a Medicare Advantage Plan to cover cost-sharing?
In short — no. You cannot simultaneous have a Medicare Advantage plan and a Medigap policy.
Medicare Advantage plans and Medigap policies serve different purposes and cannot be combined to cover cost-sharing. Medigap policies exclusively complement Original Medicare, whereas Medicare Advantage plans replace Original Medicare. Because of this, Medicare Advantage plans may require additional payments for certain services or impose specific requirements before covering your care.
Can doctors and hospitals leave a Medicare Advantage Plan at any time?
Now that you know the difference between copayments and coinsurance, you can make an informed decision about the right Medigap policy for your health care needs. If this article helped clear up the mystery of Medicare, share it with family and friends to help them make smart health care decisions, too.
