Understanding Medicare Advantage Plans 7
What are my costs? (continued)
What’s the difference between a deductible, coinsurance,
copayment, and a maximum out-of-pocket limit?
Deductible—The amount you must pay for health care or prescriptions before
Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your
other insurance begins to pay.
Coinsurance—An amount you may be required to pay as your share of the cost for
benefits after you pay any deductibles. Coinsurance is usually a percentage (for
example, 20%).
Copayment—An amount you may be required to pay as your share of the cost for
benefits after you pay any deductibles. A copayment is a fixed amount, like $30.
Maximum Out-of-Pocket Limit—Plans have a yearly limit on what you pay out of
pocket for services Part A and Part B cover. Once you reach your plan’s limit, you’ll
pay nothing for Part A and Part B services the plan covers for the rest of the year.
More cost details from each plan
If you join a Medicare Advantage Plan, review these notices you get from your plan
each year:
• Annual Notice of Change: Includes any changes in coverage, costs, provider
networks, service area, and more that will be eective in January. Your plan will
mail a copy to you, typically before September 30.
• Evidence of Coverage: Gives you details about what the plan covers, how much
you pay, and more. Your plan will send you a notice (or printed copy) by October
15, which will include information on how to access the Evidence of Coverage
electronically or request a printed copy.
Organization determinations
You or your provider can get a decision, either verbally or in writing, from your plan
in advance to find out if it covers a service, drug, or supply. You can also find out how
much you’ll have to pay. This is called an “organization determination.” Sometimes
you have to do this as prior authorization for your plan to cover the service, drug, or
supply.
You, your representative, or your doctor can request an organization determination. A
representative is someone you can appoint to help you. Your representative can be a
family member, friend, advocate, attorney, financial advisor, doctor, or someone else
who will act on your behalf. Based on your health needs, you, your representative, or
your doctor can ask for a fast decision on your organization determination request. If
your plan denies coverage, the plan must tell you in writing, and you have the right to
appeal.