Silver American Medicare Plans –

your tool for navigating the path to Medicare

Your Medicare Deductible

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.

Medicare Part A Deductible

The Medicare Part “A” deductible CHANGES EACH YEAR for each benefit period. 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.

Medicare Part B Deductible

The Medicare Part “B” benefit period is one calendar year. You must pay the Part B deductible every year. The Medicare Part B deductible CHANGES EACH YEAR …Once you pay this amount, Medicare begins paying its share of costs for covered services.

Medicare Advantage and Part D Deductibles

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.

Medicare Co-Insurance

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: $0 per day, you pay a deductible per hospital stay

• Days 61-90: a set dollar amount per day

• Days 91 through lifetime reserve days: a set dollar amount 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. 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 co-insurance amount.

Medicare Advantage Co-Pays

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 coinsurance, but these are rare. Common co-pays for a Medicare Advantage plan may be $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 Advantage Part D Out-of-Pocket Limits

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.