Does Medicare Advantage Pay 100%? Understanding Your Out-of-Pocket Costs in 2023

Over 28 million Medicare beneficiaries are enrolled in Medicare Advantage Plans in 2023. These private Medicare Plans administered by health insurers provide Medicare Part A and Part B benefits. Many Medicare Advantage enrollees choose this coverage option expecting low out-of-pocket costs. But do Medicare Advantage Plans pay 100% with no costs to members? Or will you still face deductibles, copays and coinsurance?

Understanding how much Medicare Advantage Plans cover in terms of percentages and out-of-pocket limits can help you evaluate true costs when considering Medicare Plan options.

Medicare Advantage Cost Sharing

First, a quick background on Medicare Advantage costs:

·        Medicare Advantage Plans contract with Medicare to provide coverage

·        Plans must cover all services under Original Medicare Part A and Part B premium 

·        They often include prescription drug coverage

·        Out-of-pocket costs like deductibles, copays, coinsurance vary by plan

·        Most plans have annual out-of-pocket spending limits

So while plans also must cover the same services, cost sharing amounts can differ significantly. Very few plans cover 100% with no out-of-pocket costs according to Centers for Medicare.

Typical Medicare Advantage Costs

Here are the typical costs Medicare Advantage members face, depending on their plan:

·        Monthly Premium - Average is $19/month in 2023. Many plans available with $0 premium.

·        Deductible - Average is $100 for in-network services, if plan has a deductible.

·        Doctor Visit Copay - $0 to $15 for primary care, $25-$50 for specialists.

·        Hospital Copay - $150-$400 per day for inpatient admission.

·        Skilled Nursing Facility Stay - $0 up to 20-30 days then $100+ copay per day.

·        Part D Prescription Drugs plan - $0-$5 for generics, $35-$50 for brand name drugs.

·        Annual Out-of-Pocket Maximum - $3,000 to $7,500 depending on plan.

While costs are limited compared to Original Medicare coverage, most enrollees will pay something throughout the year. Very few Medicare Advantage Plans cover 100% of costs with no member liability.

Does Medicare Advantage Have 0% Coinsurance?

Under Original Medicare, beneficiaries pay 20% of the Medicare-approved amount for most Part B services after meeting the annual deductible. This is called the Medicare Part B coinsurance.

Does Medicare Advantage cover 100% coinsurance?

·        Some Medicare Advantage Plans may cover certain services at 100% after a copayment.

·        However, most plans do not eliminate the 20% Part B deductible.

·        After your deductible, you'll typically pay 10-20% coinsurance until reaching the plan out-of-pocket limit.

Always check your specific Medicare Advantage health plan details for the coinsurance amounts for Part B services. 0% coinsurance is not very common.

Out-of-Pocket Limits

While few plans cover services 100% free for enrollees, the out-of-pocket spending limit provides strong financial protection:

·        In 2023, the most common limits are $3,900, $4,500, $5,900 and $6,700.

·        Limits apply to all in-network Medicare covered services.

·        Once you hit the limit, you pay 0% for remainder of year.

·        Plans cover 100% of costs above limit up to what Medicare approves.

So while you'll likely incur costs throughout the year, the total amount you can pay is capped.

Are Any Services Covered 100%?

While overall coverage is not 100% free under Medicare Advantage, some plans may offer certain high value services at no cost to encourage wellness.

For example, some plans provide 100% coverage with no out-of-pocket costs for:

·        Annual physical exam

·        Certain preventive cancer screenings

·        Annual vision exam

·        Hearing exam

·        Fitness program membership

·        Routine podiatry services

·        hospital care and inpatient hospital

Check your plan's specific benefits for services covered at 100% without copays or coinsurance.

Does Medicare Advantage or Supplement Cover More?

How does Medicare Advantage coverage compare to Medigap Plans?

·        Medicare Supplement (Medigap) Plans cover copays, coinsurance, and deductibles.

·        Many Medigap policyholders pay 0% out-of-pocket after premium.

·        Medicare Advantage Plans cost less on average but have copays and coinsurance.

·        Medicare Advantage limits total out-of-pocket costs.

For those seeking 100% coverage beyond premiums, a high-coverage Medigap policy may be preferable to Medicare Advantage for 2023.

Key Takeaways - Medicare Advantage Costs

In summary, answering the question "does Medicare Advantage pay 100%":

·        Very few Medicare Advantage Plans cover all services 100% free.

·        Low or $0 premiums are available, but copays and coinsurance apply.

·        Out-of-pocket maximum limits your costs for the year.

·        After limit reached, plan covers 100% of approved charges.

·        Some preventive services may be covered 100% by plan.

·        Medigap covers more out-of-pocket costs, but at a higher premium.

While Medicare Advantage provides strong financial protections, you will likely incur deductibles, copays or coinsurance when receiving medical services. Understanding your potential out-of-pocket costs allows smart Medicare Plan selection.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Bourgeois Insurance a Call at (985) 803-8999. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.

FAQS

 What is Medicare Part C?

 Medicare Part C refers to Medicare Advantage Plans. These plans are offered by private insurance companies as an alternative to Original Medicare. Medicare Advantage Plans must provide the same coverage as Parts A and B.

Do all Medicare Advantage Plans offer prescription drug coverage?

Yes, almost every Medicare Advantage Plan includes integrated Medicare Part D prescription drug coverage. With Original Medicare, you must get a separate Part D Plan for drug coverage.

What is the out-of-pocket limit for Medicare Advantage Plans?

Medicare imposes a yearly maximum out-of-pocket limit of $7,550 for in-network services on all Medicare Advantage Plans. This caps what is covered by Medicare.

 How do Medicare Advantage Plans pay doctors and hospitals?

Medicare Advantage Plans pay 100% of what Medicare pays for covered services. They may also have contracts with providers to pay negotiated amounts that differ from Original Medicare rates.

What kinds of Medicare Advantage Plans are available?

Main types include HMOs, PPOs, and Private Fee-for-Service plans. There are also Special Needs Plans tailored for specific conditions. Availability varies by location.

Does Original Medicare or Medicare Advantage offer better coverage?

 Benefits are similar, but most Medicare Advantage Plans offer extra benefits not covered by Original Medicare like dental, vision and hearing services.

 Who can enroll in a Medicare Advantage Plan?

 To join if you are new to Medicare Advantage Plan you must be enrolled in Medicare Part A and Part B and live in the plan's service area. You cannot enroll in Medicare Supplement and a Medicare Advantage Plan at the same time.

 Where can I learn more about Medicare and Medicare Advantage Plans?

Visit Medicare.gov to compare plans and learn about coverage. You can also get help through your State Health Insurance Assistance Program (SHIP) or at Medicare events in your community.

When can I join or switch Medicare Advantage Plans?

 You can enroll during Medicare's annual open enrollment from October 15 to December 7 each year, or during the Medicare Advantage open enrollment period from January 1 to March 31.

Do I need a Medigap policy if I have Medicare Advantage?

No. Medicare Supplement insurance only supplements costs in Original Medicare. Since Medicare Advantage Plans have set pay out-of-pocket limits, a Medigap policy is not needed.