Part B covers 2 types of services. Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. Qualified Medicare Beneficiary (QMB) Program: Helps pay Part A, Part B, or both Program premiums, deductibles, coinsurance, and copayments Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums Qualifying Individual (QI) Program: Helps pay Part B premiums but is limited to a first-come, first-served basis. The standard monthly premium for Medicare Part B enrollees will be $144.60 for 2020, an increase of $9.10 from $135.50 in 2019. The annual deductible for all Medicare Part B beneficiaries is $198 in 2020, an increase of $13 from the annual deductible of $185 in 2019. The standard Part B premium amount in 2021 is $148.50. Most people pay the standard Part B premium amount. If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you'll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). The standard monthly premium for Medicare Part B enrollees will be $148.50 for 2021, an increase of $3.90 from $144.60 in 2020. The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of $5 from the annual deductible of $198 in 2020.

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Generally speaking, no. This can vary a bit, depending on whether or not you have Medicare Advantage. There can also be some fees related to your doctor's visit, like prescription drug costs, that often do have a copay. We’ll go through the full structure of your out-of-pocket fees with Medicare as they relate to doctor visits, so you can know what to expect when you walk in the door.

Copay vs. Coinsurance

Copays and coinsurance fees are often discussed when you hear about your medical insurance plan. Most of the time, a copay or copayment refers to a single fee that you will have to pay when you receive health care. For example, your insurance may charge a $20 copay for each doctor visit, and you’ll have to pay this same fee no matter which services you receive at the doctor’s office.

A coinsurance functions as a percentage-based cost-sharing agreement, rather than a set fee. For example, Medicare Part B has a 20 percent coinsurance, which means that Medicare pays 80 pecent of the approved amount of your medical services, and you pay the remaining 20 percent. Some private insurance plans can have both a copay and a coinsurance for different scenarios.

Both copay and coinsurance fees will only apply after you’ve paid your annual deductible.

Does Medicare Use Copays?

Yes and no. Importantly, Part B of Medicare never uses copays. Part B has a deductible of $203per benefit period, and after this, you will pay 20 percent of your costs, which is your coinsurance. Medicare Part B covers doctor visits, as well as other things like durable medical equipment, so you will never pay a copay for a doctor visit under Original Medicare, only a coinsurance.

Mental Health Services -- The Exception

Mental health services are the one regular exception to this rule. There may be some instances in which you don't have to pay a copay for these services, but most of the time that is the arrangement that Medicare will use. Make sure to check the details with the office you are dealing with and with Medicare.

What About Part A?

Medicare Part A does not technically use a copayment, but the fees are very similar to what most people associate with copays. Part A hospital insurance uses a so-called coinsurance fee, but this fee is not percentage-based and is pre-set with a few tiers depending on the length of your skilled nursing facility or hospital stay. Because it is a pre-set fee, it does function like a copay, despite being called a coinsurance.

Copays with Medicare Advantage

When it comes to copays, Medicare Advantage is a whole other story. Medicare Advantage, or Part C, refers to a way of receiving your Medicare coverage through a private health insurance company. If you have a Medicare Advantage plan, many of the associated fees will be set by that insurance company, rather than Medicare. Although there are some regulations on these costs, there will be more variety.

This means that some Medicare Advantage plans will have copays, and others won’t. The amount of the copay will vary, and some plans may use copays for one type of care while using a coinsurance for others; it depends. If you have a Medicare Advantage plan, make sure that you know in advance what the copay is, so you can be prepared when you go see your healthcare provider.

How do Part D Prescription Drug Plans Fit In?

Although Part D plans usually won't apply to your actual doctor visit, they are still very relevant to the process. If your doctor prescribes you medication during your visit, it will usually be covered by a Part D plan. For this reason, you should make sure to understand the copay structure and out-of-pocket fees associated with your prescription drug plan, whether it’s Part D or another private plan.

Like Medicare Advantage plans, Part D plans are offered by private insurance companies. This means that they are also free to use copays, and the majority will. Prescription drug coverage is especially suited to copay structures since people refill their prescriptions often. If you have a Part D plan, it most likely uses a copay.

When it comes to Part D plans, there will usually be a tier list that has a higher copay for drugs higher on the list. If possible, try to know what the copay is before you go in to get your prescription filled.

Can Medigap Plans Help?

Medigap plans, or Medicare Supplement Plans, are plans that cover some of your Medicare out-of-pocket costs. With these plans, you will only pay a monthly premium, with no other out-of-pocket costs. As an example, these plans can cover your Part B coinsurance, and cover many other out-of-pocket fee categories. You can read more about Medigap plans at medicare.gov.

Medicare Part B Deductible 2021 Plan G

Medigap plans only cover out-of-pocket costs, so they won’t cover medical services. These plans only cover Original Medicare, not Medicare Advantage or Part D drug plans.

Medicare Part B Copayments

Because they don’t cover Medicare Advantage, Medigap plans won’t ever be able to pay for your copay. This is simply because there is no usual copay under Original Medicare. Some Medigap plans will cover the Part A coinsurance, which as we mentioned earlier, does function the same way as a copay.

Things to Keep in Mind

Overall, understanding copays with Medicare is simple, just don’t ignore it until the last minute! If you have a Medicare Advantage plan, make sure that you understand your out-of-pocket fees so a copay won’t surprise you. Otherwise, you'll rarely have to deal with copays with Medicare.

Medicare Part B Copay Amount

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