En español | You may think that when you enroll in Medicare, the federal government health insurance program will pay for everything related to your health care. It doesn’t. Tallying how much you pay out of pocket for Medicare each year can lead to serious sticker shock.
When you add up all the premiums, deductibles, copays and coinsurance, the average Medicare enrollee can expect to spend thousands of dollars a year to get medical care. And the tab can swing wildly each year, depending on the state of a beneficiary’s health, where he or she lives, and whether the government and insurers have instituted any price increases — or decreases. Individual plans can also tinker with the services and drugs they cover.
To get a better sense of the expenses you could face, the Centers for Medicare & Medicaid Services (CMS), which runs Medicare, offers an Out-of-Pocket Cost Calculator. It estimates what original Medicare and Medicare Advantage would cost beneficiaries based on where they live and the type of plan.
Consider this example: If you live in Youngstown, Ohio, are in good health, enroll in original Medicare and buy a Medicare supplement, or Medigap, policy and a Part D prescription drug plan, all with mid-priced premiums, CMS estimates that you’ll pay $5,569 out of pocket in 2021. If you sign up for a Medicare Advantage plan that includes prescription drugs with a mid-priced premium, CMS predicts you’ll pay $4,339 in 2021. These are just estimates, of course, but they can help you choose the policy that’s best for your health care needs and financial situation.
Medicare’s price tag, deciphered
Medicare covers the majority of your health care expenses each year. But you still may have to pay thousands of dollars in out-of-pocket costs:
Need help affording Medicare?
Medicare’s out-of-pocket costs — premiums, deductibles, copays and coinsurance — can easily result in a large tab each year. If you’re struggling to meet those expenses, you might be eligible for federal and state assistance.
If you qualify for Medicaid, the federal-state health insurance program for people with low incomes and individuals with disabilities, it will pay some or all of your out-of-pocket expenses. Individuals on both Medicare and Medicaid are known as “dual eligibles.”
Other programs are designed for beneficiaries with incomes that are too high to qualify for Medicaid but who still have trouble paying their health care bills. Each program has specific income and asset limits and eligibility requirements that are adjusted annually.
- The Qualified Medicare Beneficiary (QMB) program helps pay for Part A and Part B premiums as well as deductibles, coinsurance and copays. If you qualify for this program, you automatically qualify for the Extra Help prescription drug program to help you with the out-of-pocket costs of your medicines. This program has the lowest income threshold of the four.
Medicare will pay for beneficiaries to get tested for COVID-19 with no out-of-pocket expenses. During the coronavirus, deductibles and copays for people on Original Medicare and those who have Medicare Advantage plans also will be waived for medical services related to testing, such as going to the doctor or hospital emergency room to see if they need to be tested.
If you cannot leave your home, Medicare will allow your doctor to order a test to be brought to you and administered there.
- The Specified Low-Income Medicare Beneficiary (SLMB) program helps pay only for Part B premiums, not the Part A premium or other cost sharing. If your income is too high to qualify for the QMB program, you might qualify for this one. You also automatically qualify for Extra Help for prescription drugs. The Extra Help program is designed to help people with limited resources pay for Part D prescription drug plan premiums, deductibles and copays. You can apply through the Social Security Administration.
- The Qualifying Individual (QI) program only helps pay for Part B premiums, not the Part A premium or other cost sharing. If your income is too high for QMB and SLMB, you might qualify for QI. To get help from this program, you must reapply for benefits every year. Funding is limited, so these benefits are first come, first served. Priority is given to individuals who received help through this program the previous year.
- The Qualified Disabled and Working Individuals (QDWI) program only helps pay for Part A premiums. This program is designed for individuals with disabilities, under 65, who are currently working.
Your state Medicaid program or State Health Insurance Program — also known as SHIP (877-839-2675) — can provide enrollment assistance and more details on the income caps and other eligibility criteria.
Editor’s note: This story has been updated with 2021 information.