There are copays for specific items under Original Medicare, such as EKG screenings and outpatient hospital visits. Medicare Part B charges coinsurance for outpatient doctor visits and emergency room visits once you have paid your out-of-pocket deductible. These costs are generally 20 percent of the Medicare-approved costs for the treatment, service, or item. Medicare Advantage plans (Part C) charge copays for doctor visits and specialist visits.
Services for prevention, diagnosis, and treatment of conditions are covered by Part B. You pay nothing for the initial “Welcome to Medicare” visit with your doctor. Your yearly “wellness” visits are also covered in full unless they perform additional tests or services not covered by preventive benefits during the same visit, for which you may have coinsurance to pay.
How Do Copays Work?
Copayments go toward the out-of-pocket deductible, which for Part B is $203 in 2021. These are charges for services or items not covered in full by your health insurance, meaning they are not preventive services. Once you have paid enough in copayments to reach the amount of your deductible, you will start paying coinsurance.
Coinsurance is part of cost sharing, whereby you and your health insurance work together to pay for your healthcare. Your insurance pays a set portion of the full amount for covered services, and you pay the remaining portion. For Medicare, coinsurance is standardized at 20 percent of the Medicare-approved amount for covered services, treatments, and items. This Medicare-approved amount is what helps to drastically lower large medical bills. While the hospital may charge exorbitantly high rates, you will only have to pay 20 percent of the Medicare-approved amount for that covered service.
Services that require a copay under Medicare:
- Blood processing and handling
- Cardiac rehabilitation programs in hospital outpatient settings
- Diagnostic laboratory tests done in a hospital outpatient setting
- EKG or ECG screenings done at a hospital or hospital-owned clinic
- Emergency department visits and hospital services
- Eye exams for diabetes done in a hospital outpatient setting
- Foot care (medically necessary) in a hospital outpatient setting
- Glaucoma tests done in a hospital outpatient setting
- Hearing and balance exams done in a hospital outpatient setting
- Hospice care prescription drugs
- Macular degeneration tests and treatment in a hospital outpatient setting
- Mental health care at a hospital outpatient clinic or hospital outpatient department
- Opioid use disorder treatment services
- Outpatient hospital services
- Outpatient medical and surgical services and supplies
- Pain management in a hospital outpatient clinic or hospital outpatient department
- Prescription drugs (outpatient)
- Prostate cancer screenings in a hospital outpatient setting
- Pulmonary rehabilitation programs in a hospital outpatient setting
- Radiation therapy if outpatient
- Screening barium enemas in a hospital outpatient setting
- Screening colonoscopies in a hospital setting
- Screening flexible sigmoidoscopies if the procedure is considered diagnostic
- Surgical dressing services in a hospital outpatient setting
- Urgently needed care in a hospital outpatient setting
- X-rays in a hospital outpatient setting
For more information regarding Medicare copays and other costs, reach out to Bobby Brock Insurance today.