Before enrolling in a Medicare Advantage/Part C (MA) health plan, check for out-of-pocket costs which can include premiums, deductibles, and copayments. Here’s what you should expect to pay out-of-pocket throughout the year if you’re enrolled in a Medicare Advantage/Part C plan.

Medicare Advantage/Part C Out-of-Pocket 2022 Costs

Part C Premium

Can vary from $0 to $200+ (estimated average monthly MA plan premium for 2022 is $19)

Medicare Part C Deductible

Varies, typically just Part B and prescription drug coverage deductible

Copayments/Coinsurance*

Varies depending on plan and service(s) received. Maximum out-of-pocket spending limit is $7,550

*Copayments may be required for doctors’ visits, specialist visits, labs, etc.

Premiums

Premiums are the amount you pay each month out-of-pocket for your Medicare Advantage (MA) plan. This cost may vary significantly. Some could be $0, while others could have premiums over $200.

To join an MA plan, you must also be enrolled in Medicare Parts A & B. It’s important to remember that Part B has a separate premium that you are responsible for paying even if you enroll in a Medicare Advantage/Part C plan. You may pay more if you delayed enrolling into Medicare Part B and have a penalty, have higher income, and/or have under 40 Social Security work credits.

Deductibles

A deductible is the amount paid out of pocket by a beneficiary or insured individual before benefits begin. Only some Medicare Advantage plans have an annual medical deductible. However, many Medicare Advantage plans that include Part D/prescription drug coverage may charge another deductible for drug coverage.

Copayments/Coinsurance

Copayment/Coinsurance are the portion of cost you pay for covered drugs or service like doctors’ visits, also referred to as cost-sharing. The amount varies, but copays are usually a flat fee while coinsurance is not a fixed dollar amount. Instead, it is a percentage of the cost of the item/service that the patient must pay. For example, a 25% coinsurance means that the patient is responsible for 25% of cost while the plan covers 75% of the cost. Keep in mind that plans often charge higher copay and co-insurance amounts for out-of-network providers.

Maximum Out-of-Pocket Costs

These out-of-pocket costs (premiums, deductibles, and copayment) vary in each MA plan and can change every year, but the maximum out-of-pocket spending limit is consistent for all plans. For 2022 the max you will spend is $7,550. The out-of-pocket maximum for plans that allow you to see out of network providers may be higher.  If your Medicare Advantage plan includes prescription drug coverage you will have a separate out-of-pocket maximum for prescription drug costs.

Additional Considerations

  • If you’re enrolled in an HMO, you’ll need a referral from your primary care physician to visit a specialist and there is a separate copay for that appointment.
  • If you’re enrolled in an HMO, be sure that any specialist you see refers you to an in-network lab or testing facility.
  • If you’re enrolled in a Special Needs Plan (SNP) most of your out-of-pocket costs are typically covered by Medicare and Medicaid.

There are lots of considerations when choosing a Medicare plan. Don’t hesitate to speak with a Medicare expert about your options.