What is the maximum out-of-pocket expense with Medicare?
If you're wondering what is the maximum out-of-pocket expense with Medicare, then you may not be happy to find out that there are no out-of-pocket maximums for most traditional Medicare. Instead, the maximum out-of-pocket expense with Medicare is on Part C, limiting private insurers. Because of the maximum out-of-pocket expense with Medicare, most seniors pay around $5,460 a year in out-of-pocket costs.
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Michelle Robbins
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Michelle Robbins has been a licensed insurance agent for over 13 years. Her career began in the real estate industry, supporting local realtors with Title Insurance. After several years, Michelle shifted to real estate home warranty insurance, where she managed a territory of over 100 miles of real estate professionals. Later, Agent Robbins obtained more licensing and experience serving families a...
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UPDATED: Nov 8, 2023
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UPDATED: Nov 8, 2023
It’s all about you. We want to help you make the right coverage choices.
Advertiser Disclosure: We strive to help you make confident insurance decisions. Comparison shopping should be easy. We are not affiliated with any one insurance provider and cannot guarantee quotes from any single provider.
Our insurance industry partnerships don’t influence our content. Our opinions are our own. To compare quotes from many different insurance providers please enter your ZIP code above to use the free quote tool. The more quotes you compare, the more chances to save.
On This Page
- Medicare Part A and B don’t have out-of-pocket maximums
- Private insurers under Part C all have a set out-of-pocket maximum
- According to a non-profit, Medicare patients spent $5,460 a year on out-of-pocket costs
What is the maximum out-of-pocket expense with Medicare? For traditional Medicare health insurance coverage, there aren’t many out-pocket maximums. However, Part C through private insurers does have a set out-of-pocket maximum.
While you’re researching the maximum out-of-pocket expense with Medicare, enter your ZIP code into our free quote tool to get an idea of what you could pay.
What are Medicare out-of-pocket expenses?
When you’re enrolled in the Medicare health insurance program, you’ll still be responsible for some of the costs for your visit.
These costs are referred to as out-of-pocket expenses. These expenses add up to your out-of-pocket maximum, which is the amount when your insurer takes on the total cost.
How do the Medicare Parts dictate out-of-pocket expenses?
Medicare is split up into multiple Parts to simplify coverage and make processing claims easier. Each Part of Medicare has its own rules about out-of-pocket maximums.
According to the official Medicare.gov site, these include:
- Part A: This is for any inpatient hospital stays. No out-of-pocket maximum, and there is no monthly premium for most people.
- Part B: Outpatient doctor’s visits and some medical equipment. There is also no out-of-pocket maximum.
- Part C: This is private insurance through Medicare, so everything but the Medicare Advantage out-of-pocket expenses maximum is left to the insurer.
- Part D: Part D covers many prescription drugs or vaccinations and will reach an out-of-pocket maximum when you hit the “catastrophic coverage” amount.
While there is no out-of-pocket maximum for Parts A and B, there are still limits on what Medicare will cover with those services.
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What counts towards the out-of-pocket maximum with Medicare Advantage?
Your out-of-pocket costs are what you pay that the insurance company doesn’t reimburse. Some of these costs include:
- Coinsurance
- Deductibles
- Copayments
In a more detailed explanation, your out-of-pocket costs are your share of the costs for medical treatments. Once you meet your out-of-pocket maximum, your insurance company begins taking over the costs of all your medical treatment for the rest of the benefit year.
How much do Medicare recipients have to pay out-of-pocket per year?
A non-profit organization called the Kaiser Family Foundation researched this topic. It found that Medicare recipients paid over $5,460 out-of-pocket in 2016 on:
- Premiums
- Deductibles
- Coinsurance
- Copayments
While these costs might seem like a lot, it’s more affordable than senior coverage at a traditional insurer and even more so than paying for treatment outright.
The out-of-pocket maximum with a Medicare Advantage plan (Part C) is set at $7,550, but can change each year.
That is the most that you can pay if you have an Advantage plan, regardless of your medical costs.
What should I know about Medicare costs?
The official Medicare site offers some insight into the costs that a patient can expect from traditional Medicare. These costs include a $1,484 deductible, after which you have a $0 coinsurance for your first 60 days in the hospital.
For outpatient care, you can expect to pay a monthly premium of around $170 in 2022. For Medicare Part B, you have a $233 deductible. After you meet this deductible, you pay 20% of the approved amount.
As previously mentioned, Part C premiums vary between private insures. Part C also varies depending on which drug plan you choose.
How can I save on my Medicare expenses?
Everyone goes through hard times. To that end, you can find help getting more affordable medical costs and coverage through Medicare or other government programs. Some of these options include:
- Extra Help – To help cover costs, this plan helps pay for Part D, such as the premiums and expenses when you fill your prescriptions.
- Medicare savings programs – Medicare offers four separate programs to help you save on your premiums. Programs vary by state.
- Medicaid – Depending on your state’s expansion, you may qualify for more healthcare savings through Medicaid, which is specifically designed to help low-income individuals.
How do poor people get health insurance? With these openly advertised programs, you can get some form of help paying for your health insurance costs.
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Medicare Out-of-Pocket Maximum: The Bottom Line
Now that you know there is no maximum out-of-pocket expense with Medicare in most cases, you can plan your finances accordingly. Considering most traditional Medicare patients pay upwards of $5,000 a year, you may want to consider additional savings options.
As you research the maximum out-of-pocket expenses with Medicare, enter your ZIP code into our free quote tool to see what you could pay at a private insurer.
Frequently Asked Questions
What is the maximum out-of-pocket (MOOP) expense with Medicare?
The maximum out-of-pocket expense with Medicare refers to the maximum amount you will have to pay for covered services in a given year. It is the limit on the total amount you will have to spend out of your own pocket for deductibles, copayments, and coinsurance.
Does Medicare have a maximum out-of-pocket limit?
Yes, Medicare does have a maximum out-of-pocket limit. However, this limit varies depending on the type of Medicare coverage you have.
What is the maximum out-of-pocket limit for Original Medicare (Part A and Part B)?
For Original Medicare, there is no annual maximum out-of-pocket limit. Medicare Part A (hospital insurance) and Part B (medical insurance) have separate deductibles and cost-sharing requirements, but there is no cap on your out-of-pocket expenses.
Is there a maximum out-of-pocket limit for Medicare Advantage (Part C) plans?
Yes, Medicare Advantage plans have an annual maximum out-of-pocket limit. This limit is the maximum amount you’ll have to pay for covered services in a calendar year, including deductibles, copayments, and coinsurance. The specific limit can vary between different Medicare Advantage plans and can change annually.
What is the maximum out-of-pocket limit for Medicare Part D prescription drug plans?
Medicare Part D prescription drug plans also have an annual maximum out-of-pocket limit. This limit includes your deductible, copayments, and coinsurance for prescription drugs. Similar to Medicare Advantage plans, the maximum out-of-pocket limit for Part D plans can vary between different insurers and plans.
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Michelle Robbins
Licensed Insurance Agent
Michelle Robbins has been a licensed insurance agent for over 13 years. Her career began in the real estate industry, supporting local realtors with Title Insurance. After several years, Michelle shifted to real estate home warranty insurance, where she managed a territory of over 100 miles of real estate professionals. Later, Agent Robbins obtained more licensing and experience serving families a...
Licensed Insurance Agent
Editorial Guidelines: We are a free online resource for anyone interested in learning more about auto insurance. Our goal is to be an objective, third-party resource for everything auto insurance related. We update our site regularly, and all content is reviewed by auto insurance experts.